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I i APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 well/pump and the Rules and Regulations of the San Joaquin Local Health'District. �+- Job Address City C �M10A) _ Lot Size PM Mod ea Owner's Name 1 Address Phone ` Address License No.�L Phone ontractor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION K SYSTEM REPAIR ❑ O HER ❑ DISTANCE TO NEAREST: SEPTIC TANKi�t�GRICULTURE EWER LINES _000!t DISPOSAL FLD. � OP. LINE :2?aO z FOUNDATION WELLKAOLLe0THER WELL._/ k+ _ ITS/SUMPS [Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r r� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� DomesticlPrivate gGravel Pack ❑ Tracy ' Type of Casing `Specifications Il Public ❑ Other ❑ Delta t Depth of Grout Seal Type.of Grout I I Irrigation . r ._Approx. DetftII�)�Eastern Surface Seal Installed by :Repair Work Done Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 i Depth Filler Material (Below 501 —_ f TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.l r Installation will serve: Residence_ Commercial_-____ Other L(4 Number of living units: Number of bedrooms t 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 I t LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS l I Depth Size - Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ I j 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. .. _ - - a - - ;. 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.signatu re- 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." 1The applic must call for r quired inspections. Co ete drawing on reverse side. M Signed Title: Date: F DEePM ENT USE ONLY Application Accepted by / Data Area 6 Pit o rout nspection by Data/ �+ Final Inspection by Date Additional Comments: 0 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 t FEE i INFO AMOU//N��T DUE AMOUNT REMITTED MASH RECEIVED BY DATES PERMIT'NO. +.EH 13-24(REV.r i H 5) EH 14-2e