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APPLICATION FOR PERMIT 1�C SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1�-a•,.> : i;. -' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)r. 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 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: . f arS , W, Job Address City Lot Size 9 PM 1 t Address Phone r Q Owner's Name Contractor Address License No. Q Phone 44P 7, TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ DISTANCE,TONEAREST: SEPTIC TANKSE R LINES DISPOSAL FLD. PROP. UNE ' 2 ` FOUNDATION AGRIC LTURE LL,+ *5 OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA NS7RUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _- ' ❑ DomestO Pri�aie d Gravel Pack ❑ Tracy pe of Casing Specifications ❑ Public ❑ Other ❑ Delta D th of Grout Seal Type of Grout (� ❑ Irrigation �_Approx. Depth ' ❑ stern Su ce Seal Installed.by Repair Work Done ❑ Type of Pump H.P. State Work Done M Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material ABe-low 50=i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION (No septic systemipermitted if public sewer is available within 200 feet.) ' Installation will serve: Residence ,t Commercial_ Other Number of living units: Number of bedrooms Character of,soil to a depth of 3 feet: Water table depth " SEPTIC TANK Type/Mf++g Capacity No. Compartments PKG. TREATMENT PLT. ❑ liMethod of Disposal Distance,to nearest: Well Foundation Property Line LEACHING LINE ❑' No_ & Length of lines Total length/size � t I FILTER BED ❑ Distance to nearest: Well Foundation l Property Line I I 0- A 1 ' SEEPAGE E PITS ❑ Distance to nea►est:" Well �� Foun�datio I Number ` Depth SU 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 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: "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." �[ , The applicant must call for all required ins c'ons. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by l\1Xr►j�y` Date Area Pit or Grout Inspection y h� Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q0 Tracy 835-638S " Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l � ' FEE AMOUNT"DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. ' INFO '+ EH 13-24 I REV.1 i A 51 3.� EH 14-20 i /j