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! n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. �q Job Address 5 � T e, —6� ��®�✓ City 97'n--Ji I Al Lot Size� � � `� PM Owner s Name W�T�c r%� Address Phone Contractor'siName �� License No. a Phone ,5"d 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 IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing E: Domestic/Private C3Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation. ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION W DESTRUCTION ❑ (No septic system permitted if public sewer is -� available within 200 feet.) Installation will serve: Residence–K 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. El Distance of Disposal Distance to nearest: Well Foundation Property Line LEACHING.LINE �„ No. & Length of linesf-i� � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line R SEEPAGE PITS Depth _�? � Size # Number "4 SUMPS 0 Distance to nearest: Well Foundation Property Line � 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, 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 California." The I'cant ust call for a!I re it pectio Complete drawing on reverse side. c Signed Title: Date: 7--26 _ FOR DEPARTMENT USE ONL M P Application Accepted by %6 ., Date Area " Pit or Grout Inspection by Date` Final Inspection by Date ' Additional Comments: Ri }' ❑ 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. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWNO. CK NFO I I C' 7!_ a FH 131ll 26 MFv. 1Fm S I -