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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED i 4, (Complete in Triplicate) Applicin ation 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 compliance with San Joaquin County Ordinance No.549 for Local Health District. msewage or No. 1862 for well/pup and the Rules and Regulations of the San Joaquin i Job Address City Lot Size PM Owner's Name Address Phone Contractor Address �] v TYPE OF WELL/PUMP: License No. Phone �S� WELL RE - r ANEW WELL El ❑ ❑ PUMP INSTALLATION LlDESTRUCTION DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR El OTHER ❑ SEWER LINES DISPOSAL FLD.. FOUNDATION PROP. LINE AGRICULTURE WELL OTHER WELL 4 PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel ❑Pack Tracy Type of Casing Dia. of Well Casing � ' ❑ Public ❑ Other q i ❑ Delta Specifications Depth of Grout Seal 4 71 Irrigation __—Approx. Depth El Eastern Seal Installed by Eastern Type of Grout I , Repair Work Done ElType of Pump H p Well Destruction ❑ Wel! Sealing state Work Done_ � ealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION r _ STRUCTION ❑ {No septic system permitted if public sewer is Installation will serve: Residence available;within 200'feet.) COM Other- + - Number of livingunits: -�--- --�--- . .� Number of bedrooms,� �• Character of soil to a depth of 3 feet: i SEPTIC TANK Water table,depth ❑ Type/Mfg f❑ PKG. TREATMENT Prapacity Nos Compartments LT. - . t . Method of Disposal Distance to nearest: ..Well-.-_ __ .- Foundation - . Property Line LEACHING LINEI ❑ No. & Length of lines t FILTER BED c _ Total length/size�4 ❑ Distance to-nearest: t Well Foundation �. Property Line j . SEEPAGE PITS ❑ Depth Size .- SUMPS Number i ❑ Distanceoto nearest: Well r -Foundation DISPOSAL PONDS ❑ a - Property'Line__" i 3 _ I hereby certify that I have prepared this application`and that'the work will be done in accordance wi h San Joaquin county ordinances, state Taws a rules and regulations of the San Joaquin Local.Hea(th District. _ and r Home owner or licensed agent's signature certifies the following."'I certify that in the performance ancethe„pork for which this permit is issued, I shall not employ any person in such manner as to become subiect�to workman's compensation laws of California.”Contractor s hiring or sub-contracting signature' tionl the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion law California.' Thea lican '.., pp call for II re ire( pectin Co plete drawing on reverse sid f t Signed i Xitle' r _-i Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by ata Final Inspection by ate Additibnsl Commeni5: Cl Stk 466-6781 r G,'Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385ce Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, StG k., CA 95201 wf1.T�I� th�lo FEE AMOUNT DUE J AMOUNT REMITTED UK INFO RECEIVED BY DATE. �''f p� rt PERMIT NO. + EH14-24(REV.iiRs) !V �U syn �_�`pr„ �f jo EH 7429 [yf/ tl� (,� _. _ i x