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u APPLICATION FOR PERMIT ! --SAN JOAQUIN LOCAL HEALTH DISTRICT �5 . 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� O 1Cornplete in Triplicate) C Ply, i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describea. This 15plication is made in compliance with San Joaquin County Ordinance No.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address ° Iry 0 Lot Size PM N Owner's Name Address Phone Contractor'[� '� ` Address E License No. 1 t Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP,�INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia.of Well Excavation Dia. of Well Casing L1Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y ❑ Public 171 Other Cl Delta Depth of Grout Seal Type of Grout 1 I I Irrigation _Approx.,'Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Dong Well Destruction ❑ Well Diameter Sealing Material Itop�.501 Depthl! Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REPAIR/ADDITION I I DESTRUCTION. (No septic system permitted if public sewer is I� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Iy Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ !. Method of Disposal ` Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines — Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El I 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. f 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 taws of California."Contractors 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 applicant us calk for all required inspections. Complete drawing on r rse side. '7 Signed X Title: Date: L /5- FOR DEPARTMENT USE ONLY Application Accepted by _ Date ::;Zr_'�I��+ Area Pit or Grout Inspection by Date Final Inspection by [,J rt+rJlJ�- Date 3 �� li Additional Comments:. d. ❑ Stk 466-6781 ' ❑ Lodi -3621 U❑ Manteca 623-7104 .❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ' INFO v + EH 13-24)REV. /n 51 EH 14-28 II