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' 4 ^; �•� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CACAN Telephone (209) 466.6781 E 1) PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sanaaquin 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 Lot Size PM Owner's Name ' ��- Phone Contractar n ress Na. Phone TYPE OF WELL/PU P; VY QANEW 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ll Domestic/Private Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I' Public ❑ Other 11 Delta Depth of Grout Seal f Irrigation Type of Grout t1 -_..Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P j State Work Done _ J Well Destruction ❑ Well Diameter Seating Material itop 50' Depth Filter Material f Balo I 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 )REP WADDITION i DESTRUCTION i I (No septic system permitted if public sewer is Installation will serve: Residence_ CommercialOther available within 200 feet.) Number of Living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity r PKG. TREATMENT PLT. p No. Compartments Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE' ❑' Na.-& Length of lines TgtaLlength/size FILTER BED ❑ Distance to nearest: Well Foundation 4— Property Line .� SEEPAGE PITS I I Depth z> r p SUMP Ll Di / Nu ber Distance to nearest: Well Foundation�--ll�.ri DISPOSAL PONDS El Property Line rules and regulations of the San Joaquin Local Health District.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 1 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 ermit is issued, I shall employ tion laws of California." p p y persons subject to workman's compensa- The applicant r all i ctions. Co a drawingon er +}side. Signed X Title: Date: r RNT SE ONLY Application Accepted by Date Area Pit or Grout Inspection by f Date Final Inspection by Date Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.iirt5l .-. EH 14-26 - ` �