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nen*/ -7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT >,n 1601 E..HAZEL I ON AVE., STOCKTON, CA f�O Telephone (209) 466-6781 of '� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p (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 Lin- _ City Z Lot Size 00 V 7S __ PM :n 1)�. 5 Phone Owner's Name Address Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ _ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES` '' POSAL FLD. PROP. LINE FOUNDATION AGRICUL URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ON CTION SPECIFICATIONS i❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing y _. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of Casing t Specifications ❑ Public ❑ Other ❑ Delta Dept of Grout Seal Type of Grout ❑ Irrigation -�4pprox. Depth stem Surface Seal installed by -- `Repair Work Done ❑ Type of Pump' H.P. ` State Work Done n .,Well Destruction ❑ Well Diameter Sealing Material (top 501 2 r l fi Depth Filler Material (Below-50'1• -:'TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK Mf Type/ Capacity � No. Compartments PKG. TREATMENT PLT. L1Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �t F I SEEPAGE PITS 1:1 Depth Size Number !I' SUMPS ❑ Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ r 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 c Ados s 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 be me s 'ect to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the following:"I rt,fy that in the ormanc f the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californi .r ap lican t al for all req pec ns- Com late drawing on reverse side. c Signed Date n FOR DEPARTMENT USE ONLY Areate Application Accepted by Da Pit or Grout Inspecti Date Final Inspection by Date✓ �� ' Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manta 823-7104 ❑ Tracy 835463$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 �i FEE ;AMOUNTE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. INFO :Ej + EH 13-14(REV. EH 14.28 i