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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 IE 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 I Local Health District. / �!� C% PM G � p L/_ City � Lot Sze Job Address + � l Address Phone Q� Owner's Name 1 y ContractorY `� Address Z L' // ,J� {LSE icense No.��; Phone TYPE OF WELL/PUMP: f4EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION I SYSTEM RffAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES /._" __.._ DISPOSAL FLD. PROP. LINE AJ "f� FOUNDATION � AGRICULTURE WELL OTHER WELL �— PITS/SUMPS/� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a 4 El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 'K L] Dia. of Well Casing' ,^t Domestic/Private XGravel Pack ❑ Tracy Type of Casing C Specifications M Public [7 Other ❑ Delta Depth of Grout Seal d T pe of Grout I I Irrigation _.-Approx. De h Easterni ace Seal Installed by SS Repair Work Done 13 Type of Pump = H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJ 3 Method of Disposal s - Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. & Length of lines _ Total length/size t:. FILTER BED ❑ Distance to nearest: Well -Foundation Property Line t SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line C DISPOSAL PONDS ❑ E - 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 Di3trict. 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 compensa- tion laws of California." The applic nt must I for all required inspections. Complete drawing on revere ide. Signed le. vd` v Date: U ` IF DEPARTNINT USE ONLY +-t EM Application Accepted by Date_ t Area Pit orj�ut Inspection by ate Final Inspection by l�� ` Date g� Additional Comments: - ❑ 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 FEE INFOEEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. 1-24(AEV.1/H51 aV� 5♦�� / P