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lAPPLICATION FOR PERMIT �• SAN JOAQUIN LOCAL HEALTH DISTRICT •.M 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or'ns II the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 fell/p a d the Rules and Regulations of the San Joaquin Local Health District _1 Job Address City of Size PM Owner's Name ,Address Phone Contractor dress License No hone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU TI N ❑ 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 Y CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LI Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack •❑ Tracy Type of Casing Specifications (`l Public s (7 Other Q Delta Depth of Grout Seal Type of Grout t I I Irrigation .AP Depth-o^I ) Eastern—Surface-Seal-installed-by——• - tt " - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 ( Depth Filler Material (Belo i 8 TYPE OF SEPTIC WORK: NEW INSTALL I] REPAIR/ADDITION I DESTRUCTION I I (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 , Character of soil to a depth of 3 feet: Water table depth I I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well- Foundation Property Line LEACHING LINE ❑... No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well- Foundation ioI Property Line SEEPAGE PITS I 1 Depth1A_ Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL 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 taws, and rules and regulations of the San Joaquin Local Health District. 1 &.. i Horne 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 r 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 woik for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." "` f The applicant must at r.all r5 red inspections. mplete drawing on reverse side. Signed X Title: Data., r FOR DEPARTMENT USE ONLY G� Applic 'on Accepted by / Date 1'- r! � �s rea rout Ens ction by Date r�` ��Final Inspection by,/ �m 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, Stk., CA 95201 � I FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. 4 ♦ EH 13-24IREV.1/951 k. EH 14-26 - 1