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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL`;W tZLTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 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 well/pump and the.Rules and Regulations of the San Joaquin Local Health District. �. Job Address r �! _� ity Lot Size PM Phone Owner's Name Contractor's Na License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ l 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 El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing (� `Y 11 Domestic/Private EJ Gravel Pack L3 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane Ai Well Destruction ❑ Well Diameter Seali -Material {top 501 Depth er Material 1Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIRIADDI ION ❑ DESTRUCTION El (No septic system permitted if public sewer is F' available within 200 feet.) Installation will serve: Residence__ Commercial Other x d Number of living units: Number of blooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. T;StATMENT PLT. El - Method o�j Dis 00 7 Distance to nearest: Well�� Foundation Property L10 %44 V ine �t — t}kr LEAK Ell lh/ LEACHING LINE No. & Length of lines "' Total _ FILTER BED ❑ Distance to nearest: WeII ' Foundation Property Line SEEPAGE PITS ❑ Depth Size ' _ , Number f UUMMPPSS 7-1Distance to nearest: Well Q Foundation V•— Property Line f 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, an rules-and regulations of the San Joaquin Local Health District. How 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 to workman's compensation laws,of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject 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 'rad inspect) s. omplete drawing on arse side. , Signed Title: Date: v F RD ARTMENT USE ONLY I Date 3 : Area Application Accepted by Pit of Grout Inspection by Date' s Final Inspection by Date r Additional Comments: ❑ Stk 466-6761 ❑ Ld6i 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835- ApplEcant- Return all copies to: Envirpnmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 h _t. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. ' INFO CASwrH _. . ,.