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c APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR 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 E 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 R Local Health District. fo'e,cC&L Ga'_�o ' Q1 29 y� a City lot Size PM 1 Job Address ' �Q21s Addressili�l �Y Phone �� Owner's Name _� Contractor Address/ License No Phone_ TYPE OF WELL-/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑' OTHER QSL DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f 14 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I � , j Type of Grout � 1 Public ❑ Other C! Delta v ,Depth;of Grout 5eai _ , Depth l i Eastern Surface - I I Irrigation � ---Approx. Seal Installed by � Repair Work Done ❑ Type of Pump,, H.P. AhState Work Done Lam. Well Destruction ❑ Well Diameter. Sealing Material Itop 50'), Depth- 1. Filler Material IBelow 5011 • -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 1 DESTIAJCTION I I (No septic system permitted if public sewer is br` t: available within 200 feet.) �V Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms .• .' , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of,Disposal ik Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have piepa�ed 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, 1 shall riot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatu 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 m t c I all required inspections. Complete drawing o ��verse side. X Title: -(y4ai t L, Date- Signed k F R DEPARTMENT USE ONLY �J r Application Accepted by Date/ -4 Area Pit or Grout Inspection by Date Final Inspection by e,7 Date Z �O ` Additional Comments: -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT No. INFO GASH i ..EH13-24(REV.1/451O— EH 14-26 �3