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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Vl/ 1601 E. HAZELTON AVE., STOCKTON, CA ?/ j 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. f Job Address / City r Lot Size PM Owner's Name ___ Address j�� Phone `t 4 Contractor � �"' "' " � Address ` 3� License NoJ�_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. E —, FOUNDATION AGRICULTURE WELL OTHER WELL S/SUMPS INTENDED USE -.TYPE OF WELL PROBLEM AREA CONSTRUCTION SP IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack i❑ Tracy T Type of Casing Specifications f`l Public ❑ Other 4H Delta Depth of Grout Seal Type of Grout i I Irrigation _Approx. Depth astern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTIO)%KNo septic system permitted if public sewer is 1 available within 200 feet.I Installation will servo: 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line f SEEPAGE PITS I I Depth Size _ Number SUMPS L1 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 laws, and rules and regulations of the San Joaquin Local Health Di§trict.. 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, Ishall 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 ) 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 st call for all requir ins tions. Complete drawing on reverse side. �.�. �Z Signed X - Title: Date: FOR DEP RTMENT USE ONLY ` Ap cation Accepted by Data /Z Area Pit or Grout Inspection by Date Final Inspection by / Date Additional Comments: ❑ Stk 466-6787 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. + EH124fREV.r/x51 1 71 EH 104-28