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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZELTON 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 and Regulations of the San Joaquin Local Health District. Job Addre City Lot Size PM Own^ am '� Address ' Phone 1 C ftr ! Addres License 2 Q Phone U�� TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT ❑ DESTRUCTION ❑ # PUMP INSTALLATION C4 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 E] Manteca Dia. of Well Excavation Dia. of Well Casing i;�-Damestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Gro t ❑ Irrigation ---Approx. Deoh J Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r`"" State Work Done t'u Well Destruction ❑ Well Diameter Sealing Material;(top 50')- Depth " Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) t �a t `1 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 Capacity1 No. Compartments C PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation " Property Line LEACHING LINE ❑ No. & Length of lines p Total length/size FILTER BED F1Distance to nearest: Well Foundation -` a Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 per n in such manner as to bet a bject to orkm,.'s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo wing: "I certify that in the or ante of a work for which t ' rmit is issued,I shall employ persons subject to workman's compensa- 1 m tion laws of alifarnia." ' The applica m g4c fo a ra c ons. Co ete drawing o eve side. Signed A Title: Date t F R DEPARTMENT USE ONLY Application Accepted by nItAv _ __ Date ' � Area d Pit or Grout Inspection by Date Firial Inspection by Date Additional Comments: t ❑ 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 20119, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE cf�PEER�MIT'NO. 4 + EH13-24 IREV.1/e 51 EH 14-26 c i