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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 anis Regulations of the San Joaquin Local Health District. Job Address t � City Lot Size vM Owner's Name Adress Phone Contractor's Name (cense No. 41 Phone TYPE OF WELL/PUMP: z 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LI.Gravel Pack ❑ Tracy Type of Casing_ Specifications �❑ Public ❑ Other ❑ Delta Depth of Grout Seale M-' - -- "Type of Grout t ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. il State Work-Done Well Destruction ❑ Well Diameter s Sealing Material (top 501 Depth .* Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTA [ON ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence!— Commercial Other Number of living units: Number of bedrooms d { I Character of soil to a depth of 3 feet: 4 Water table depth (Q SEPTIC TANK Ll Type/Mfg G� Capacity No. Compartments G` v PKG. TREATMENT PLT. ❑ DistaMethod o� is sal J� nce to nearest: well y Property Line LEACHING LINE ❑ No. & Length of trines Total length/size FILTER BED ❑ Distance to ' "'Well -F6—.Wdation _ �— Property Line_. 10 SEEPAGE,PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 1 Foundation T� Property Line DISPOSAL PONDS ❑ t 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 1 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 mu t call f or al r wired ins Ins. Complete dr wing on reverse side. r� ' Signed Title: Date: r FOR DEPARTMENTUSEONLY �7 Application Accepted by Date v Area r� Pit or Grout Inspection b Date Final Inspection by Date 0 Pe Y 'L Additional Comments: 1� D ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M :Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a CK FEE REMITTED RECEIVED BY DATE PERMIT"NQ. INFO AMOUNT DUE AMOUNT CASH + EH 13-24(REV.10J83Y 70 Ek 1 428