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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � I 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 we11/pump and the Rules and Regulations of the San Joaquin Local Health District. I1 r PM Q( City Lot Size Job Address �_ I Owner's Name —� �L�T � ddress Phone Cantractaq r ry e U4ess License No. Phone �(�y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"i Public 1=1 Other F1 Delta Depth of Grout Seal Type of Grout---- i rout __i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by— Repair y - Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter k Sealing Material Itop 50'1 Filler Material IBelow 50'1 6I c / 7 Depth / TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I 1 JNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms 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 Size Number SUMPS ❑ Distance to nearest: Well Foundation 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, an rules and regulations of the San Joaquin Local Health Di'ktrict. 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, I shall employ persons subject to workman's compensa- tion laws of Cali'or The applic t t9byt ns. Complete drawing on rev a side. on Signed X Title: Date: FOR DEPARTMENT USE ONLY Application AccepteDate �, 1 Area 3 Pit or Grout Inspection by Date Final Inspection by Date LC2�5 / Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-1621 ❑ 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 CASH RECEIVED BY DATE PERMIT-NO. INFO Gf + EH 13-24(REV.tiH ,5 5) J "- y s-� f`( ^' 97 EH 14-26