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I. APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT~," a 1601 E. HAZELTON AVE.,'STOCKTON, CA I' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ;{ i (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.' t ED n r\cl 0l i ( ,, Job Address City Lot Size Owner's Name _V"ddress 1 r Phone 4(..;)�5WIS Contractor v ss icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE it FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 0Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private =- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications h, M Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diametei Sealing Material {top 50'1 Ir 1 Depth T Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION I.'1 REPAIR/ADDITION I I DESTRUCTION o septic system permitted if public sewer is i+ 0 'available within 200 feet.) 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 Capacity No. Compartments PKG. TREATMENT PLT. C1 ." Method of Disposal Proper 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 r3 SEEPAGE PITS 11 Depth Size Number - SUMPS ❑" Distance to nearest: Well Foundation Property Line 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, arld ._ 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." i? The applica t call for all r quir d i ions Complete drawing o reverse std ; Signed X Title: p Date: I� 4 FOR DEPARTMENT USE ONLY I Application Accepted by �� Q j Date Area Pit or Grout Inspection by _ Data Final Inspection by 1 Date r Additional Comments: CL�c>� .� 6 v ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca -7104 Tr cy 83$_6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK + G INFO CAS}( RECEIVED BY DATE ZPIERMIT'NO. EH 1241REV.1iEH 11;4,18wl/O�p