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APPLICATION FOR PERMIT 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 andlor 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 Distrfet. Job Address i City Lot Site PM 1 Owner's Name Address _1; Phone - Contractor Address JLicense fJo- Phone_ rY TYPE OF WELL/PUMP: NEW WELL Q.. WELL REPLACEMENT f] DESTRUCTION,p PUMP INSTALLATION Q SYSTEM REPAIR Q OTHER D DISTANCE TO NEAREST: SEPTIC TANK _� _ SEWER LINES DISPOSAL FLO. r PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I-1 Open Bottom 0 Manteca Dia. of Well Excavation .j ') � Dia- of Well Casing [J;,Domestic/Private -LISravel Pack CI Tracy Type of Casio g JaSpecifications i'i Public (] Other fl Delta Depth of Grout Seal _ Type of Grout i lrrillation ___.Approx. Depth I ] Eastern Surface Sual Installed by ` Repair Work Dane L7 Type of Pump J --b H.P. 1 State Work Done Well Destruction C7 Well Diameter Sealing Material flop 50'1 _ Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No se ticsystem permitted if public sewer is � 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 f SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest, Well _ Foundation Property Line i LEACHING LINE 0 No. & Length of lines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L) Distance to nearest Well Foundation Property Line DISPOSAL PONDS CI 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: 1 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 Sall for all re fired inspections. Complete drawing on reverse side. Signed X Title: fTITPE i Date: �J FOR DEPARTMENT USE ONLY Application Accepted by Q Date C� ? Area ? t Pit orGrou inspection by at - y� U Final lnspeclio by Date Additional Comments: � � U Stk 466.6781 ❑ L i 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 f Applicant • Return all copies to; Environmental Health Permit/Services 1601 E. Hezetton A've., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM r .•M 1J JPERMI7'NO. ry ' J 0EH 1. /0, /-2 F a x