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T ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 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 A City 45 64 Lot Size PM Owner's Name Address Phone �j CorltrLicense No. Phone?�s�7�Z TYPE OF WELL/PUMP: NEW 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 yfr F-1Industrial ❑ Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing I] Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ PV(—_ _ _ _ Specifications 1 Public Alunr�v i r eA-d f`l fl Other 11 Delta Depth of Grout Seal J� Type of Grout . W� z I Irrigation pp p y_, �( (t�_A rox. Depth l 1 Eastern Surface Seal Installed b �'Pmk Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIAODITION l I DESTRUCTION [ I (No septic system permitted if public sewer is f` available within 200 feet.) Insta will serve: Residence_ Commercial_ Other Number ofliv ng Number of bedrooms Character of soil to a depth of ater table depth SEPTIC TANK ❑ Type/Mfg Ca No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Founda Property Line LEACHING LINE ❑ No. & of lines Tatal len ize FILTER BED ❑ stance to nearest: Well Foundation Property 1 SEEPAGE PI I Depth Size Number SUM D Distance to nearest: Well Foundation Property Line 01`SPOSAL ❑ 1 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 applicoft must call for all r quired in pections. Complete drawing on reverse side. Signed X F Title: /�/ - Date: DEPARTMENT USE pNLY 01 Application Accepted by 1 date !�I Z z � Area D Pit or Grout Inspection by Date Final Inspection by t� 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 RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.t/Hs1 EH 14-2e •.J