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APPLICATION FOR PERMIT I/ A14 SAN JOAQUIN LOCAL HEALTH DISTRICT ( p 1601 E. HAZE T ON AVE. STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C � (Complete in Triplicate) F 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. /� �4 d�i� City q Jab Address of Size PM r � II t Owner's NameAddress Phone Z III Contractor Address License No. Phone Fl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ jl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FE:D�*r- -t= PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` h C1Industrial Lli Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ElGravel Pack ❑ Tracy Type of Casing L;;iSpecifications � ('1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') !� TYPE OF SEPTIC WORK: _NEW-INSTALLATION-fTI-�@wREPAIRl-ADDITIO_N_{I D.EST_RU_CTION_ -(No-septic-system permitted if public sewer is available within 200 feet.i T I !� Installation will serve: Residence_ Commercial_ Other T Number of living units: Number of bedrooms li Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1i "Type/Mfg =+..� Capacity No. Compartments ' PKG. TREATMENT PLT. ® Method of Disposal Distance to nearest: Well foundation Property Line y y ` LEACHING LINE L11 No. & Length of lines Total ler�gih%ize II FILTER BED ❑y. Distance to nearest: Well Foundation Property Line !I SEEPAGE PITS i I Depth Size Number Ii SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application lication 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. `i II 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, 1 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." II I I The applicant+must call for all requuiired inspections. Complete drawing on reverse side. i Signed X c JLY-4 Title:_ � Date: "� � • F R DEPARTMENT USE ONLY Application Accepted byDate d 7 Area� 13 { � � Pit or Grout Inspection by P� Y Date Final Ins ettion'b Additional Comments: _11616 /�1 r I �— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 II Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 i FEE AMOUNT DUE AMOUNT REMITTED CK 0+�J RECEIVED BY D PERMr IT'NO^. INFO CASH EN 324 � 4 na7p � �7 EH 1 }