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Iri , I! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT !� 1601 E. HAZEL T ON AVE., STOCKTON, CA �I Telephone (209) 466-6781 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 welltpump and the Rules and Regulations of the San Joaquin Local Health District. 'I Job Address @' City Lot Size III, Owner's Name Address Phone w I Contractor -_{ 11'Address License No. Phone , .;.TYPE OF WELL/PUMP: NEW WELL MI, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL;FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL's PROBLEM AREA CONSTRUCTION SPECIFICATIONS T '� ❑ Industrial ❑ Op n Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing t, L9'Domestic/Private ravel Pack El Tracy Type of Casing VC., Specifications 1-1 Public F1 Other ❑ Delta Depth of Grout Seal t `Ty e of Grout – p I I Irrigation _..Approx. Depth I I Eastern `' Surface Seal Installed bye "1 Repair Work Done ❑ Type of Pump '#"4i *. Lit State Work Done Well Destruction ❑ Well Diameter p Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAI )ADDITION Ll DES UCTION I I.INo septic.system permitted if 'public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ 0th 4 1. Number of living units: Number of bedrooms f "� .A I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK '❑ Type/Mfg Capacity No. Compartments m PKG. TREATMENT PLT._O4 ,; Method of Disposal t Distance to nearest: Well 1Z Foundatio Property Line A LEACHING LINE ❑ No. & Length of lines tal length/size FILTER BED ❑ Distance to nearest: ell Foundation Property Line a SEEPAGE PITS l I Depth II Size ' _ Number 1 SUMPS Ll 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, 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, Isshall 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." F The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR MENT USE ONLY Application Accepted by I O`^�`'�' Date rea Pit or ou nspection by Date Final Inspection by Date ... Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 O Tracy 835-5385 ! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED:BY DATE PERMIT'NO. INFO + EH 13-24(REV.1/85) / 0�� ,✓,��J /r Q� `° sY ��a�U EH 14-2e