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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p� Telephone (209) 466-6781 11�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q A, (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 �9�plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or Na- 1862 for well/pump and the Rules an rthe San Joaquin Local Health District f } I V� Job Address v �r e • City Lot Size PM x � r Owner's Name R VAddress •�`� Phonet� � Contractor ./ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �.` PUMP INSTALLATIONK SYSTEM REPAIR dTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL T PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ,. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout KIrrigarion Approx. Depth l I Eastern Surface Seal Installed by r _ -$,.Repair Work Done¢ ❑ Type of Pump H.P. State Work Done . „ ,}Well Destruction ❑ Well Diameter Sealing Material (top 501' , Depth Filler Material (Below 501 IIi TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTI I I (No septic system permitted if,public sewer is 1 available within 200 feet:)- 1 1 Installation will serve: Residence_ Commercial Other / -- Number of living'.units: Number of bedrooms •+ Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 0 Distance to nearest: Well F ation Property Line Uj LEACHING LINE ❑ No. & Length of lines Z Tota! length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line i SEEPAGE PITS I I Depth Size Nu er SUMPS 1=1 Distance to nearest: We Foundation operty Line DISPOSAL PONDS El ' �l�hereby..cartify_that-l-have prepared_ttus.-applisatioia-and-that-the-work-will-ba-done-in-accordance-with San Joaquin-county-ord'+nances; state-laws-and--P rules and regulations of the San Joaquin Local Health District. -✓1 Home owner or-licensed agent's signature certifies the fallowing: "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 Californi." 11 V / The applicant must all for all ed ins ctions. Complete drawing on reverse side. J r .' !D ,Signed X Title: _. y w+c.e�� _--'- __ Date: FOR—DEPARTMENT USE ONLY Application Accepted by Date �` Are ^� C� Pit or Grout Inspection by_ Date '_ ' Final Inspection bjr DateG 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO �1 I� Qom} (� 7 a EH 13-21[REV.1/R 5) v V ��. V CJ "'1Bq) D W „ ��'O V ! g 1 'y J� EH 14-28