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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 k . PERMIT EXPIRES TYEAR 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 10 Local Health District- �1 G��.� x, r7 A� I Job Address City of Size PM 1 r Owner's Name r Address Phone Contractor = Address License No Phone 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` m �. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 7 Public 1=1 Other Cl Delta Depth ofGrout Seal Type of Grout---- I I Irrigation —..Approz Depth "l-1 S astr3m" 5uriace Seal Installedby, Repair.Work Done ❑ Type of_Pump - H.P.- --- -State Work Done I Well Destruction ❑ Well.Diameter Sealing Material Itop 501 I -- pepth — - •- Filler Material (Below 50') f TYPE OF SEPTIC WORK; NEW INSTALLATION YREPAIR/ADDITION l I DESTRUCTION I l'lfdo iseptic 'system permitted if public sewer is r77 wadable within 200 feet.) Installation will serve: Resl"ddnte�_� 'Commercial Other ' < f'•� ;r» t 3 - /� Number of living units: , Numher of bedrooms c: , Character of soil to a depth of 3 feeU:- table depth. SEPTIC TANK ❑ Type/Mfg _`_-�; ' I Capacity No. Compartments PKG, TREATMENT PLT. ❑ :., v °�. t ' ^ - Method of Disposal Distance to nearesi: Wel! :FoundatioJt _..___� Property Line 9" M LEACHING LINE Nw& Length-af-lines - - - - - -+Total-length•/size' FILTER BED' ' ,-• Distance to nearest: Well�T Foundation/GIZ27 Property Line�� ; �SEEPAGE PITS l I Depth Size / Number SUMPS L7 Distance to nearest: Wel! "` Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application ana`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. C, Home owner or licensed agent's signature certifies the following: "ll-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 California." t The applicant must call for IIreq ired inspection's. Complete drawing on reverse side. F Signed X - Title: �, _ Date: R DEP TNIENT SE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CK RECEIVED BY DATE PERMITNO. INFO CASH 13.2 IFEV_V.n.5Y