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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �V 1601 E. HAZETON AVE-, STOCKTON, CA Telephone (209) 466-6781 _ r 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 ` �� ' City Lot Size ' /QPM Owner's Name Address Phone + Contractor assmic License No. . Phone I TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL__ PITS/SUMPS _ I f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -> -Dia.-of-Well-Excavation-- Dia. of Well Casing Domestic/Private O Gravel Pack ❑ Tracy ) Type of Casing_ Specifications _ i'1 Public 'Other 1 Fl Delta + Depth of Grout Seal Type of Grout I I Irrigation ..Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of-Pump H.P 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IaREPAIR/ADDDTIDNDESTRUCTI 1 1 I septic system permitted if public sewer is ( �t citable within 200 feet.) l . r { Installation will serve: Residence _ Commercial Other_ Number of living units: Number of bedrooms + /a►�/ -`� Character of soil to a depth of 3 feet: 1 ater table depth SEPTIC TANK ❑ Type/Mfg ,Capacity No. Compartments PKG. TREATMENT PLT. ❑ t� Method of Disposal Distance to-nearest: Well Foundation Property Line O LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line -- r E SEEPAGE PITS I I Depth Size Number r I SUMPS Ll Distance to nearest: Well--—Foundation -_ Property Line DISPOSAL PONDS ❑ 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 Di§trict. �. 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 applicant ust call fo t'require d spec ions. Complete drawing on reverse side. Signed X ^ Title: Q�fn�� / Date: t FOR DEPARTMENT USE ONLY t Application Accepted by Date r Area I E Pit or Grout Inspection by bate Final Inspection by Date -r arc Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-66385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -FEE DUF— �-AMOUNT.REMITTED OK RECEIVED BY- �....DATE- PEAMIT NO. INFO C;ksH—"'" I EH 13-24(REV. !t EH 14.2e f