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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �"- R" ; PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby 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. Job Address / D /"' r City Is Size PM Owner's Nam Address Phone J Contractor ddress License No Phone -'� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1 SYSTEM REPAIR W OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE tt FOUNDATION AGRICULTURE WELL OTHER WELL Plfs/SUMPS INTENDED USE TYPE OF WELLt PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom ❑ Manteca Dia. of"Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q M Public n Other C] Delta Depth of Grout Seal r Type of Grout --- I l Irrigation --Approx. Depth I 1 Eastern St�rf a Seal Installed by _ Repair Work Done VC Type of Pump H,P. State Work Done P Well Destruction ❑` Well Diameter - -Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve:'+Residence_ 'Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: r ' Water table depth SEPTIC"TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ ��, Method of Disposal Distance to nearest: Well Foundation ' ' > Property Line LEACHING LINE ❑ No. R Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t, 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 co ensa- tion taws of California." The applicant all for all required ' specti s. Co ete drawing on revbtse side. ' tl Signed Title: Date: FOR DEPARTMENT USE ONLY �r Application Accepted by �L Y Date Area D r Pit or Grout Inspection by Date Fina! Inspection by � Date / 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 ,E Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 4 INFO AMOUNT DUE AM`O��UUN/T`REMITTED CASH RECEIVED BY DATE; PERMIT"NO. t.EH 7324(REV.I/H sl' - -!� ( �/lf- fa EH 14-26