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i APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / 70 yr Job Address City Lot Size PM r !Ei(l�T Owner's Name s Phone Contractor'effi Address License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications F1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done C Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is l /� available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: —I— Number of drooms Character of soil to a depth of 3 feet: ; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-4 60 No. Compartments PKG. TREATMENT PLT. D Method of DisposaA Distance to nearest: Well 6--(9 0 Foundation� Property Line__._..777 __.._ LEACHING LINE k 1❑ No. & Length of lines A D Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line — SEEPAGE PITS 11 Depth x Size � ,, Number P S Ll Distance to nearest: Well Foundation ALL Property Line SAL PONDS ❑ I hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ~ rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all rreq d 1 spections. C irlate drawing on averse side. 7// Signed X //! �. Title: Z';. Date: /L� d/j/ i FOR DEPARTMENT USE ONLY C_J Application Accepted by 1IN Date a~ Area �� Pit or Grout Inspection by Date Final Inspection byr Date C- Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A�plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERIVIIT'NO.�% + EH 13-24tREV.I/A51 l 400 EH 14.26