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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 rPERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete%in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Co Local Health District. ` City {,rr� Lot Size PM Job Address Owner's Name { Address ! Phone Address - icense No. Contractor Phone TYPE OF WELL/P,UMP< ,�y-. .,NEW-.WELL ❑,-', `�.e..WELL REPLACEMENT �, DESTRUCTION ❑ -A, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El '� gg�� DISTANCE TO NEAREST: SEPTIC TANK v SEWER LINES DISPOSAL FLD./d PROP. LINE.,_2_ FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rhJ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �1 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r- {_1 Other ❑ delta Depth of Grout Seal Type of Grout i`l Public �. _ I I Irrigation —_Approx._Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ a Well Destruction ❑ Well Diameter t Sealing Material itop 50') Depth Filler Material loalow 501 } TYPE OF SEPTIC WORK: NEW INSTA LLATION l 1 REPAIR/ADDITION I i DESTRUCTION I i ii septi system yst m permitted if public sewer is Installation will serve: Residence 4 Commercial Other 4 . I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - ` No. Compartments Method of Disposal, I Pi TREATMENT PLT. 11way Distance to nearest: Well Foundation Property Line __ q F F _ LEACHING LINE ❑ No. & Length of linesT�Total length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line Number SEEPAGE PITS I'] Depth Size „�. Well Foundation i Property Line SUMPS 0 Distance to nearest: I 5 ;.,�.v j,-_.....f DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will,be done in accor,t nce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agents signature certifies the following: "I certify that in-the 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: 111 certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of Calif mia." { The applicant st call for aH requ d inspections. Complete drawing on r arse Sided t X Title: �� /1 Date: Signed [[ -FOR DE ARTMENT USE ONLY F Date Area Application Accepted by i 7 Pit or Grout Inspection by Date ,Final Inspection by Date' r 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 CASIV H RECEIVED BY DATE PERMIT'NO. INFO 74 r EH 13-24(REV.1/x s) C.l�� [S 1 ,.+.,,....,.,., �.�/,".',,;,� �.�.+�..-� "�,^"'' _ a.. EH 14-26