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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT I' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T'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 and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address s r ' Phone f � Contractor Address zZil- License No Phone �T TYPE OF WELL/P MP: NEW WELL-L] WELL REPLACEMENT ❑ DESTRUCTI N ❑ r PUMP INSTALLATION ❑ ISYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL Y OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well,Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 f'l Public F1 Other n Delta Depth of Grout Seal Type of Grout "1 I I Irrigation _`_Approx. Depth I 1 Eastern �.Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. * State Work Done _41- Well Destruction ❑ Wel! Diameter Sealing`Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION i.l DESTRUCTION Na septic system permitted-if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial Other k Number of living units: Number of b9edr53ims I Character of soil to a dept of 3 feet: ' # Water table depth SEPTIC TANK C1Type/Mf 9 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Dlsp9WI Distance to nearest: Wed-D.1 Foundation Property Line C/ LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell _ Foundation Property Line - r � SEEPAGE PITS I I Depth Size ' Number SUMPS L1 Distance to nearest: Well Foundation " P'roperty Line DISPOSAL PONDS ❑ R 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. 4 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 or all requ 's tions. Comp drawing on r verse side. Signed X Title: ! Date: , - � FOR DEPARTMENT USE ONLY Application Accepted by _ -__ Date 8 / 7re�a —4— 1 Pit or Grout Inspection by Date Final Inspection by Date 7 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT.NO. INFO CASH + EH 13-21[REV.t/x 5) EH 14-26 UX r p[