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Jf{ OVA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED (Complete in 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 Lot Size M Owner's Name Address r Phone Contractor AddressG License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR,15• OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL T PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, ; Type of'Casing s~ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ElEastern i Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Yiop''I s Depth _ _ FillerWaterial IBelow_50') TYPE OF SEPTIC WORK: %NEW INSTALLATION .AEPAIWADD.ITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation}wilhseiroe Resid ice_ Commercial Other t -Numie�of"lining uriits:' Number of bedrooms r , i i Character of soil to a d of-3.feet: - Water table depth ,. SEPTIC TANK Type/Mfg Capacity No. Compartments z f Disposa ^" + Methodl" PKG.TREATMENT OCT.T ❑ Distance to nearest: Well .— Foundations Property Line S� LEACHING L'INEI No, & Length,of lines, - Total length/size ' FILTER BEDS ❑ Distande to nearest:' ' Well, 'Foundation'�� Property Line LA SEEPAGE PITS Depth Size N?mber _ SUMPS a t ❑ Distance to nearest: Well Foundation/-a Property Line r,-% DISPOSAL PONDS a! 17 1 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 rules and regulations of the San Joaquin Local Health District. 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: "l 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." .t The applicant must f r all r uir inspectio Complete drawing on reverse side. Signed Title-, -s _ Date: FOR DEPARTMENT USE ONLY Application Accepted b,;- Pit yPit or Grout Inspection by c Date 9 34 Final Inspection by Date Additional Comments: l; �f 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 E h FEE INFO AMOUNT SUE AMOUNT REMITTED-_1 SH RECEIVED BY DATE PERMIT'NO. + EH 14-24 IREV.1/B 51 EH 1428 Ll ` t