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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name ress Phone Contractor resS �- e No Phone d TYPE OF WELL/PUMP: NEW WEtL ❑ WELL REPLACEMENT ❑' DESTRUCTION ET 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 ❑ Tracy Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation '--Approx. Depth —1 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ p Well Destruction ❑ Well Diameter. Sealing Material Itop 501) �J Depth Filter Material (e to ) LIU TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I IN. septic system permitted if public sewer is f" available within 200 feet.) Installation will serve: Re dente— Commercial_ Other Number of living units:.--J— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 13 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F) rt Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE . No. 8r Length of lines( Total length/size ILTER BED ❑ Distance to nearest: Well Foundatio �� 73S Property Line SEEPAGE PITS I I Depth Size Number v" i SUMPS ❑ Distance to nearest:' Well _ Foundation Property Line DISPOSAL 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 Diltrict. 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 subcontracting 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 applican t c r r .ed i ti ns. Complete drawing on reverse side. e?/927 Y_ Signed X Title: Date: r FOR DEPARTMENT USE ONLY Q _ Application Accepted by Date + �C� Ar a Pit or Grout Inspection by Date Final Inspection by 4Dt r, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO A�MOUNTpD�UE AMOUNT REMITTED CK 9 CASH RECEIVED BY PATE PERMIT NO. +.EH1 -24fREV.tin5l EH 144-26 1 y • IDr�„J,-J 1