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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE+ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES T 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 weli1pump and the Rules and Regulations of the San Joaquin Local Health District r" Size.City Lot Job Address Aadress Phone Owner's Name p to7 icense No: Contractor l Phone 1 Yl Address Q TYPE OF WELLJPUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION El PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ 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 CONSTRUCTION SPECIFICATIONS Dia. of Well Casing -3Industrial ❑ Open Bottom, El Manteca Dia. of Well Excavation ' Type of Casing— asing Specifications ❑ Domestic/Private: ❑ Gravel Pack ❑ Tracy,,,t Type of Grout l'l Public t�' n Other 71 Delta Depth of Grout Seal I I Irrigation tG- "=Approx.,Depth ,,;,-I I Eastern. 4 Surface Seal Installed by Repair Work Done ED ;,,Type-of Pump H.P. State Work Done _ Q Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 50'1 U} TYPE OF SEPTIC„WORK: NEW INSTALLATION.1:1 REPAIR/ADDITION DESTRUCTION I I al o septic system t m rented if public sewer is 4 - Installation will sdrve: Residence Commercial_ Other I Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3-feet; - — SEPTIC TANK C1,hype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . s � LEACHING LINE .Q' No. & Length of lines �� Total length/size FILTER BED Cl , �[�Distance to nearest: WeII Foundation Property Line SEEPA PITS Il Depth t Size l� X 1 � �� _Number 1.-0�- Property Line _ SUMP q? Distance to nearest: Well� Foundation �� l s DISPOSAL PONDS U �- - / aro 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 Di§trict. 11L 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 per is issued, I shall employ persons subject to workman's compensa- k tion laws of California." The applic�Muyfor all required in i 1s. Co plate Jte drawing on reverse side. Signed X le: Date: (J OR DEPARTMENT USE ONLY Area -- Application Accepted by Date Pit or Grout Inspection b Date Final Inspection by�; Date Additional Comments: El Stk 466-6781 I❑ 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 7 CK 4F CASH RECEIVED BY DATE ZPEMIT NO. INFO +.EH 13-24(REV.r/H 51 0 EH 14-29