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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL:HEALTH DISTRICT i 1601 E. HAZEL ION AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = (Complete in Triplicate) k 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 Ryles and Regulations of the San Joaquin Local Health District: '- s» Job Address I/ �� ''' City Lot Size PM Owner's Name- ^ r Address Phone Contractor Address [ icense No.Wd;32j�)__Phone —y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El. SYSTEM REPAIR OTHER 11 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 t CONSTRUCTION SPECIFICATIONS �� El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing )1 Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications :f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by ai i it Repair Work Done ❑ Type of Pum H.H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50'1. _ Depth Filler Material (Below 5D')� Vi TYPE OF SEPTIC WORK:,NEW.-INSTALLATIQN g REPAIR/ADDITION-D-DESTRUCTJON_❑_,(lVoyseptic.sys tem_permittedd if-public sewerfis - � n � available within 200 feet.) Installation will serve: Residence 'GommerciaL _Other ,:.rte- -' y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f -- A Water table depth f SEPTIC TANK i O Type/Mfg. ° ;=' y" " ^" Capacity t j No. Compartments ` PKG, TREATMENT PLT. ❑i Method of Disposal f Distance to neatest: .,Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sizes r FILTER BED Ll Distance to nearest: Well Foundation Property Line,' -� SEEPAGE PITS ❑ Depth ( Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lire 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 JoaquinHealth ealth District. 4- 1 followin : "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the g fy 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 applicant ust aH all required inspections. Complete drawing on verse side. Signed Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date '? Area f Pit or Grout Inspection by � Date Final Inspection b Dat Additional Comments: I 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ti AMOUNT REMITTED SH RECEIVED BY . DATE PERMITNO. INFO I + EH 13-24(REV.1/ss) Fl EH 1428 �I E