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a it APPLICATION FOR PERMIT I� SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i � (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 Health District. �E City - a Lot Size PM Job Address Owner's Name Udress �- Phone Contractor Address License No, Phone PE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 L3Gravel Pack ❑ Tr cy Type of Casing Specifications ❑ Public ❑ Other ' ❑�D"elta 11 Depth of Grout Seal Type of Grout ;. I I Irricfation —.-Approx. Depth'^ l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump ' y H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION i I DESTRUCTION I No septic system permitted if public sewer is available within 200 feet.) lbs Installation will serve: ' Residence '_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:I Water table depth SEPTIC TANK ❑ Type/fiA{g Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ . �Y ��, , , _ „ x .. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of linesnR Total length/size - - FILTER BED` O Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth'6 Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ ii 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,ap ficant must call r all required inspections. Complete drawing on reverse side. 1 0 Date: Si ed X Title. 1R. FO NT USE ONLY yl ,E Application Accepted by Data j Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + INFO CASH + EH 13241REV.tiH5) 2�J 00 EH 14-28 �3