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f APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT i(91601 E. HAZEL i ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1;YEAR FROM DATE ISSUED } l , + , . (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.' - r ok Job Address City Lot Size PM — Owner's Name Address * " ` Phone Contractor reqs License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 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 ❑IManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑;Tracy Type of Casing Specifications ❑ Public r1❑ Other•. " ❑ Delta Depth of Grout Seal Type of Grout \ �< t ❑ Irrigation �4pprox�Depth ❑;Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 50') i Depth Filler Material {Below TYPE OF SEPTIC,WORK: NEW INSTALLATION ❑. REPAIRIADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is _ I.- ___K__ __ r -F I available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of-bedrooms Character of soih:to a depth of 3'feet a 1`i � Water table depth l SEPTIC TANG ❑ Type/Mfg.. y` s Capacity No. Compartments PKG. TREATMENT.,fPI-T. 1-1Methodof Disposal + r- Distanc�4 Wele to nearest: l undation Property Line S LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ODepth Size Number VDI MP -r Distance to nearest: Well Fouhdation Property Line i POSAL PONDS ❑ 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 I 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." ' i .., i ' E The applicant`"-sf call for-all iequir i s #ions:Completed ing'on rr g e side. SignedTitle:� ��G��n ��-�— Date: FOR DEPARTMENT; SE ONLY . Application Accepted by w ""�_� Date /rea Pit or Grout Inspection by Date Final Inspection by tt w J�y Date Additional Comments: uQ ❑ Stk 466-6781 7 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy SNOW Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE- AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 1124(REV.V8.5) EH I4-25 V