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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 i 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District, Job Add�e City �'"'r��'ze PM Address ! ` Phone s ZLS, wner's Nam �^ Contractor �Cicense No. 6 Phone��' TYPE OF WELL/PUMP: N WELL❑ WELL REPLACEM T ❑ DESTRUCTION El PUMP INSTALLATIONS SYSTEM REPAIR E] OTHER F1DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD.t 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 Excavatio l Dia. of Well Casing _ -' XRomestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications f'1 Public ❑ Other Cl Delta Depth of Grout Se:aI r,Type of Grout _. A rox. De th 1 1 Eastern Surface Seal Installed by ` �( ` I 1 Irrigation .» PP 1 � � Repair Work Done ❑ Type of Pum H.P. J State 'Work Done �• u Well Destruction ❑ Well Diameter .. Sealing Material /top 50'1 Depth T I�,S Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW-INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION I I (No septic systerrl permitted if public sewer is available within 200`feet.) Installation will serve: Residence— Commercial_w_._ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth, 1 A` ,e—SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartmentg, 4 'PKG. TREATMENT PLT. ❑ '! Method of DisOosal i I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 'No=_&f Length of lines Total length/size FILTER BED_ ❑ #Distance tc nearest: Well Foundation . Property Line r/ f SEEPAGE PITS l'I Depth Size Number SUMPS' �, C1 Distance to nearest: Well Foundation Property Line T—DISPOSAL-PONDS•.a. ._.❑�, _ 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. 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." i The applicant st call frequired inspections. Complete drawing on r rse side. Signed C, 404J - Title: Date: l A10R DEPARTMENT USE ONL +• f�j �`f .l f Area' ,n s Application Accepted by � Date � Pit or Grout Inspection by date Final Inspection by —) Date�� C` Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ` INFO CASH +.EH 13-24(REV,t n 5) EH 14-26 14r