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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephorle (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f � -', � 9j OU0 Job Address /`[� ,dr1 City Lot Size PM Owners Name J /"I[Lit Ili[! Address 91 file Phone Contractor , Address cIlJri License Nay r3� l Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'lel ' SEWER LINES DISPOSAL FLD. PROP. LINE �� i• FOUNDATIONSf� _ AGRICULTURE WELL � OTHER WELL PITS/SUMPS l-JL- AGRICULTURE USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation Open /12 1 Dia. of Well Casing Domestic/Private IVGravel Pack ❑ Tracy Type of Casing /�f/L Specifications /did Public n Other F Delta Depth of Grout Seal .$�!7 Type of Grout I I Irrigation oTWO_4pprox. Depth I I Eastern Surface Seal Installed by 's7aR/4�O Repair Work Done ❑ Type of Pump -51 Al H.P. �� _w State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION [ I (No septic system permitted if public sewer.is f available within 200 feet.) Installation will serve? Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet`: Water table depth r SEPTIC TANK C1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ci No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 applicant must call for a required insp3a:z7itlo: Cowing on reverse side, Signed X Date: ( R DEPARTMENT USE ONLY ApplicationAccepted by Date Area �� Y Pit or Grout Inspection by / Date Final I pection by ,_ Date' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma eca 823-7104 . . ❑ Tracy 836-6385 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 C CK 0RECEIVED BY DATE PERMIT ND. INFO t I +.EN 13.24(REV.tIK5) � }�� `-i EN 14-29 I