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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA S Telephone (209) 466-6781 �p�3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F'1f�i!?0e (Complete in Triplicate) MNM RAS MFA Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describeVQ � lication 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. Job Address 12 931, a d �'Ge .� City�O�/. Lot Size PM Owner's Name Address Z _ �� Phone Contractor &_ Address License No. , Phoned ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial E) Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing domestic/Private LJ'Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth It Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump —S%W.� H.P. 6te State Work Done_ f �Q Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if publicseweris 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. ❑ Method of Disposal 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 SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 6 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, 1 shall not employ any person in such manner as to become subject to workman's compensation taws 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 m t call for all r q d inspections. omplate drawing on reverse side. Signe Title, Date: FOR D (�EPARTMENT USE ONLY Application Accepted by —lyl _—OLDate `�� Area `�' Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. l 13-24(REV,i/h 5) .Y 1.26 8