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C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E�fiJ-IAZEL T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t ,.,,,(Completein 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 /L. ,Lot size PM Owner's Name Phone Contractor d d r e s s d License No. 5 Phone ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION i] ! PUMP INSTALLATION )W SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK,.--------,-- SEWER LINES DISPOSAL FLD"1ZZ�t"PROP. LINE lj�5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing WDomestic/Private OGravei Pack ❑ Tracy Type of Casing Sr .L ;, Specifications • U , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout D�tI ❑ Irrigation AZ_�Approx. Depth ❑ Eastern Surface Seal Installed by A99V Repair Work Done ❑ Type of Pump H.P. State Work Bone Well Destruction ❑ Well Diameter Sealing Material itop 50')� ��Uepth —Filler–c–material-(Below.50'.)— _ TYPE OF`SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION_D (No septic system permitted if public sewer is _ – - available within 200 feet.) I nstallation will serve: Residence_^Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table\\\\depth 1 .`"fi _ SEPTICITANK C7 Type/Mfg Capacity . No. Compartments \- PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation Property Line _ (� I� �j LEACHING LINE L2 No'. & Leng Ih of lines Total length/size i' r FIiITER 1BED ❑ Distance to nearest: Well Foundation Property Line SE'/EPAG'E PITS EJ Depth i Size Number �*4 S`MPS� ❑, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ L'hebyrecertify that I have prepared this application and that the work will be done in accordance with San`;,Joaquin county ordinances, state laws,land rules anis regulations of the San Joaquin Local Health District, t � 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 fii�ing�or sub-contracting signature cer4ifieslthe following: "I certify that in the performance of the work for which this permit is issued,Ishall employ persons subject,to,workman's compensa- tioA laws of California." � The applicant mu call r required ins ctions. Complete drawing on reverse s"r e. y` 01) Signed X Title: –S ._ Date: 1' FOR DEPARTMENT USE ONLY Ap lication Accepted by + Date Pit or 'rout spection by Date Final Inspection by F ` hs a �' At. I Additional Comments: Sik 1466-6781 ❑ Lodi 369-3621 ❑ Manteca :823-7104 ❑ Tracy 835-6385 g ct ppli - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'20m_ Stk., CA.9W1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE ��. INFO _�PER34VIT NO. w_ } _CASHT r EH 13-24(REV.1 i n 5) 1.�� EH 14-28,.- -�—..