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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephorle (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (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 compliant with San Joaquin Coun Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dis t' �. Job Address — Lot Size PM Owner's Name ,}— Address Phone I Contractor � m ( L Address 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Graver Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal'f Type of Grout _ I I Irrigation _._Approx. Depth I I Eastern Surface Seal Inst la led by.'` - Repair Work Done ❑ Type of Pump H.P. _fState Work- one _ { Well Destruction ❑ Well Diameter Sealing Material (top/50'1 f Depth Filler Material 1 Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION'1 I DESTRUCTIONVAINo'septic system permitted if public sewer is VJ s, ilable within 200.feet.l 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 SEPTIC TANK ❑ Type/Mfg A� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: %�',W� Foundation Property Line LEACHING LINE ❑ No. & Length of lines "�- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' J 4 SEEPAGE PITS I I Depth Size — Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 Di�trict. 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 pe su manner as to become subject to workman's compensation laws of California." Contractor's hiring+or sub-contracting signature certifies the f to g c rtify 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 ali r ' The applican II required inspections. Complete drawing on reverse sid Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date C' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ! ❑ 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, Silk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ..EH 13-24 IREV.s/14 51 EH 1426