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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! / 1601 E. HAZEL T ON AVE., STO ` CKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED madeApplication is hareby made to tfie San Joaquin Local Health District urea permite in t Triplicate) made!n is with San Joaquin County Ordinance Health 549 for sewage or No Local Health District. construct and/or install the work herein described. T his 1862 for well/pump and the Rules and Regulations of the SanliJoaquin Job Address Owner's City Lot Size PM Address Contractor s� ` Phone AddressS- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ License No. PUMP::INSTALLATION p �- DISTANCE TO NEAREST: DESTRUCTION ❑ Phone SEPTIC TANK SYSTEM REPAIR ❑ -�� SEWER LINES OTHER ❑ FOUNDATION �� DISPOSAL FLD. INTENDED USE AGRICULTURE WELL �— PROP. LINE TYPE OF WELL PROBLEM AREA �� OTHER WELL _ PITS/SUMPS ❑ industrial ❑ Open Bottom CONSTRUCTION SPECIFICATIONS ❑ Domestic/Private ❑ Man~teca Dia. of Well Excavation ❑ Grave! Pack ❑ Tracy Dia. of Well Casing f"i Public Type of Casing C7 Other I I Irrigation ❑ Delta Depth of Grout Seal Specifications — APprox. Depth I 1 Eastern Type of Grout Repair Work Done ❑ Type of Pump Surface Seal Installed by Well DestructionCl —`—�— H.P. Well MarketerState Work Done Depth - t\ —� Sealing Material (top 50'1 -------- j TYPE OF SEPTIC WORK: Filter Material (Below 50'1 NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system ' Installation will serve: Residence Commercial Permitted if public sewer available within 200 feet.l 's Number of living units: r� -- Other J i Character of soil ber of bedrooms to a depth of 3 get ti� SEPTIC TANK ❑ Type/Mfg I 1 Water table depth PKG. TREATMENT PLT. ❑ Capacity ' No. Compartments Distance to nearest: Well � Method of Disposal �1 Foundation Property.Line LEACHING LINE' ❑ a No, & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size r Foundation Property Line •� SEEPAGE PITS i I Depth i \ Size i Number SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Property Line f 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:A'f.certify that in the performance of the work for which this permit is issued, I shalt 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 all for all re inspections. Complete drawing on reverse side. ' Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1�_ -� '� rea �F Pit or Grout Inspection by Date Final Inspection by Dat i Additional Comments: ❑ Stk 466-6781 O Lodi 369421 ❑ 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 95201CK a # FEE AMOUNT DUE" AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO a 1,2 .EH 13-24 IREV.1 EH 14-29 j _,•