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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 4 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. f � •` � � �" Job Address City Lot Size PM f Owner's Name Address �� Phone r \ Contractor �/w _. Address ` m License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION-LJ— `^ SYSTEM REPAIR ❑ OTHER ❑ _ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESp. _DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Diarof-Well-Excavation Dia:of Well Casing ' "❑.Domestic/Private ❑ Gravel Pack ❑ Tracy "riVe of Casing ,Specifications, ' M.. I"1 Public ❑ Other { Ll Delta """"' Depth of Grout Seal'""" '.ii,/Type of Grout I I Irrigation —..Approx.-Depth I I Eastern Surface Seal.installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 F Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION l I INo septici,system permitted if public sewer is available within 200 feet_) Installation will serve: Resi nce Commercial_ Other x Number of living units: Number of b droa s Character of soil to a depth of 3 feet Water table depth. SEPTIC TANK ❑ Type/Mfg Capacity (/� No. Compartments 1f� PKG. TREATMENT PLT. ❑ Method of Disposal K . Distance nearest: Well Foundation *�' Property.Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distanceito nearest: Well r7-0-'/_—Faundab,n Property Line 1 SEEPAGE PITS < Depth Size r _ Number SUMPS ❑ Distance to nearest: Well .Foundation Property Line :.p, DISPOSAL PONDS ❑ s .w 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 Diktrict. — .,. 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 taws 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,1 shall employ persons subject to workman's compensa- tion laws of California." ! The applicant must tali for all requir inspe ns. Complete drawing on reverse side., / f� 1� Signed X Title: Date: F G f FOR DEPARTMENT USE ONLY Application Accepted by Date G S Area 1 Pit or Grout Inspection by , e 7- /'� Final Inspection by Date ✓` " f Additional Comments: c ❑ 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 ' INFO FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY PATE PER NO. r.EH 133-28 IREV. 6) <) EH 1 -28