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APPLICATION FOR PERMITco --�® SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL%T ON AVE., STOCKTON, CA Telephone (209) 466-6781 � 5 PERMIT EXPIRES.A,YEAR FROM DATE ISSUED ;� ? (Complete in Triplicate) 7 .; I 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. 18612 for well/pump and the Rules and'fiegniex�f8ns of"San Joaquin Local Health District. !! C I�Job Address City Lot Size PM Owner's Name Address 11 Phone i Contractor Addres d gusorf ense No Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ .. II -SYSTEM REPAIR ❑ OTHER ❑ L.. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP. LINE • FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca .y Dia. of Well Excavation Dia. of Well Casing ` �Damestic/Private ❑ Gravel Pack ❑ Tracy i; Type of Casing Specifications f'] Public ED Other ❑ Delta n Depth of Grout Seal Type of Grout —.-- I i Irrigation —"Approx. Depth i I Eastern Surface Seal installed by r Repair Work Done Type of Pump H.P. dW,, � _._ State Work Donex ' Well Destruction ❑ Well Diameter. Sealing Material-,(top 50'1 A MW DepthFiller Material (Below"50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is R f available within 200 feet.) �-—Installation will serve: Residence_ Commercial_ Other 00 Number of living units:___ Number-of bedrooms �~ y Character of soil to a de th of 3 feet: J p Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT.µ❑5 i� + Method of Disposal Distance to,nearest: Well �� Foundation J Property Line LEACHING LINE ❑ No. & Length of lines Total length/size y FILTER BED O .Distance to'nearest: Well 11 Foundation Property Line ] SEEPAGE PITS"' '"' 'I-) Depth I Size Number ' 1 SUMPS ❑ Distance totnearest: Well li Foundation t Property Line DISPOSAL PONDS ❑ 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. i1 K Home owner or licensed agent's signature,certifies_the following:.;;1 certify that in the-performanEe of the work'for which this-permit is issued, I shall not 1 employ any person in such manner as to become subject to wo(kman'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." '�--� ._. • ) � ' C-.A . i II. r The applic�tmustcaallrequir�ispe�cfions. ompletedrawing ort reverse side.ASigned Title: ._. Date: sL i+ F DEPARTMENT USE ONLY I Application Accepted by �+ T Date Area 7 i Pit or Grout Inspection by Date Final Inspection by�� Date 9-M 11 Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7,104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE , Il INFO AMOUNt DUE AMOUNT REMITTED CASH'` RECEIVED BY DATE PERMIT NO. I +.EH13.24 1REV.t i e sl EH 14-2e I 1 ly