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APPLICATION FOR PERMIT \�\ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE. STOCKTON, CA j� Telephone (209) 466-6781 ,4 ti PERMIT EXPIRES i YEAR FROM DATE ISSN (Complete in Triplicate) `C� a�wQa Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or insta work her Rg�f�f ed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules aerations of the San Joaquin Local Health District. � y _ r p Job Address u City � �r Lat'Size PM Owner's Name r Address} � . r V Phone � �...r)�t Contractor Address f License No.tYJfo�L—Ay Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION/ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .;-.FOUNDATION. _ - AGRICULTURE WELL ------.-.OTHER-WELL PITStSOMPS INTEND'_D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- . ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack .-.-❑-Tracy. - Y- Type of'Casing .Specifications , �— a Public ❑ Otrer .? C1 Delta Depth of Grout Seal Type of Grout I Irrigation ,fe..Approx.-Dept l I Eastern Surface Seal installed by Repair Work Done A Type of Pump H.P. ��(�r�� State Work Do !� Well Destruction ❑ Well Diameter !a Sealing Material atop 50'l t f s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C) REPAIRIADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms 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 t i i .. LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number I t _,. SUMP_S ,,;,,� ._,❑_;;Distance.to nearest- .,Well Foundation Pr.opertyJ_ine_ 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 rules and regulations of the San Joaquin Local Health District.. Home owner or licensed ant's signature certifies the followirig:'"i certify that in the performance of the work for which this permit is issued, I shall not employ any person ins ch _ nner as to become subject to workman's compensation taws of California."Contractor`s hiring or sub-contracting signature certifies the following: 'I ce f that in a performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californi ." The applicant mu a or all quire inspe s Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY °-� Application Accepted by Date �3 Area OJ Pit or Grout lnspection,6�4/ Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY `` DATE PERMIT NO. + EH 13-24(REV.rixbf EH 14.26 l