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APPLICATION FOR PERMIT r SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 n'�� C7 • i} PERMIT EXPIRES 1YEAR FROM DATE ISSUED2 f (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a.permit to construct and/or install thework her n described. TThiscatio Local Health District. I 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 i y'► ob Address City-53t Size PM Owner's Name _® Address Phone 4 Cpntractor y� - 4 Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTIDN ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE _ I FOUNDATION _AGRLgk LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ', PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel PackDia. of Well Casing f] Othe ❑ Tracy;, ` Type of Casing Specifications ! I Irrigation s f'1 Public ❑Delta Depth of Grout Seal _ qr - Type of Grout _ .. pprax. Depth � {•I Eastern Suriaca Seal Installed by Repair Work Done ❑ Type of Pump y p - "` State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I I-REPAIWADDITION I 1 DES I RUC71pN- .-(.No,septic system permitted if public sewer is favailable within 200 feet.) Installation wil! serve:' Residence_ Commercial Other. s Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: SEPTIC TANK EI Water table depth Type/Mfg Ca acity :- P - No. Compartments PKG. TREATMENT PLT. C1 E i,,�_..._ y, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PiTS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 3 , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iand r 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, iTa,1',Iemploy any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting ture not 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 ust tali for all required inspections. Complete drawing on reverse side. Signed X + Title: Date: FOR MARTIVIENT USE ONLY Application Accepted by 1 (� Date �o ti] Area f7` Pit or Grout Inspection by Date Final Inspection t Data- El Additional Comments: O ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ 1 FEE AMOUNT DUE AMOUNT REMITTED C INFO AS ;C� D BY p /D.A.,T�+E�f �iPERMIT'Nd. + ER 13-24(REV.r i x 5) EH 14-28 cJ ' or