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=� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 O'ncri PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)Application is he!eby made to the San Joaquin Local Health District for a permit to construct and/or install the work application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules f the n Joaquin Local Health District. Job Address A City of Sized Owner's Nam ddress Phon a Contractor 5T___ (_e Address License No. Phone TYR,E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE TIC TANK SEWER LINES DISPOSAL FLD. PROP. LI FOUNDA AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED•USE r TYPE OF WELL PRO REA CONSTRUC CIFICATIONS ? ❑ Industrial ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack racy Type of Cas+ Specifications 1-1 Public ❑ 0 {l Delta Depth of Grout Seal Type of Grout . I I Irrigation --Approx. Depth i 1 Eastern Surface Seal Insialled by Repair W one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 F Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted if public sewer is , i vailable 4within'200 feet.) Installation will serve: Residence Commercial_ Other -+' I Number of living units: Number of bedrooms t j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity € No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well Foundation :Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS i I Depth I Size Number SUMPS C1 Distance to nearest: Well Foundation v n Property Line DISPOSAL PONDS ❑ 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 m rules and regulations of the San Joaquin Local Health District. r 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: "],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." The applicant st call for IIrequired i oti Com to drawing on verse side. Signed X ! Title: ( JiF�1�/lsf�!/t r Date: Ir A—-VA57 7 FOR DEPARTMENT USE ONLY Application Accepted by Date , 1-7� Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: 1-�`-�^— gwL ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 835-6385 � Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , S t., ' _(07 FEEPb CJ U INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY ATE PERMI�T'NO. f + EEH 3-24 H 1�26IREV.tixsf i