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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT iF. 1601 E. HAZE i ON 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule and Regulations of the San Joaquin r 1 Local Health District. S`�O Job Address Size - ply Owner's Name _. Address 111 Phone Contracto Address License No. d' Phone TYPE OF WELL/PUMP NWV WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 5� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V' `' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS !i. INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.--of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications EJ Public ❑ Other ❑ Delta Depth of Grout ut SeaE Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well.Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is VV available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: _/_ Number of bedrooms Character of soli 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 .ILl—No. & Length of lines e'er Total length:/size FILTER BED ❑ Distance td nearest: Well Foundation; en ` Property Line- D SEEPAGE PITS Sid s a .. plum e6 r""" I` V SUMPS Distance to nearest: Well ' Foundation. r y�D Property Line � DISPOSAL PONDS ❑ s A 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 t rules and regulations of the San Joaquin Local Health District. , Homeowner 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." i The applica ust call for all required in ction:s�gm f q FJ plate drawing on reverse side. Signed 3 Title: Date: `- .FOR DEPA �ENT�USELY Application Accepted by I ` f/ "�� bate` Area FF Pit or Grout Inspection by Dat Final Inspection by Date 7 r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 G FEE AMOUNT DUE AMOUNT REMITTED CASH CK# RECEIVED BY DATE PERMIT�'NO. �� INFO ' + EH 13-24 IREV. EH 14-26 6 i I