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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA f/ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} Application is heieby 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 / U City SizeS42'F Aw PM Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /'17 r SEWER LINES ZOT DISPOSAL FLD. t/� PROP. LINE �a FOUNDATION AGRICULTURE WELL OTHER WELL y3',_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 19 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other ❑ Delta Depth of Grout Seal � ! Type of Grout I I Irrigation _Approx, Depth l I Eastern S ria ce Seal Installed byb� - Repair Work Done ❑ Type of Pump — H.P. [ State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 Y_ i. Depth Filler Material (Below 50') �-- TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1 I DESTRUCTION [ I (No septic system permitted it public sewer is available within 200 feet.I tallation will serve: Residence_ Commercial_ Other Number ing units: Number of bedrooms Character of soil to th of 3 feet: Water table depth SEPTIC TANK ❑ y f Capacity . ompartments PKG. TREATMENT PLT. L1Method of Disposal Distance to nearest: F on Property Line LEACHING LINE ❑ No. & Len s Total length/size FILTER BED ance to nearest: Well Foundation Property Line SEEPA E PIT5 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requiA ins tione Qm A drawing on reverse side. Signed X %?eei��ZTitle: Date: _ZI�IvAv_ FOR DEPARTME T USE ONLY ? r Application Accepted byet7 Date "/ r Area Pit or Grout Inspectio Date��1b99 Final Inspection by Date Additional Comments: (L, G { o r L^ 4 ❑ 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 CK RECEIVED BY DATE PERMIT NO. + EH 13INFO 1 CASH 21[RfV.i/n 57 1©�, (,� " ' �"' • �� EH 14-2e 1