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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. �O Y Job Address �I Cit t S�ize(�,, P/M l Owner's Name ddress hone f Contractor - Address License No. 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. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout-- I rout I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 -- I TYPE OF SEPTIC WORK: NEW INSTALLATION.[') --.REPAIRIADDITION l-I DESTRUCTIO (No septic system permitted if public sewer is O available within 200 feet.) Installation will serve: Residence' Commercial Other I r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:--, Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ ...---•--� Method of Disposal Distance to nearest: Well :-.----Foundation----•; Property Line LEACHING LINE ❑ No. & Length of lines i Total length/size (,I FILTER BED ❑ Distance to nearest: Well Foundation —_Property Line I SEEPAGE PITS { I Depth Size 1 'f Numbed'='�- = 3 •r i SUMPS ❑ Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that Me work will_b_e dorle_in.acgordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di?;trict.�� i 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 CaliforniaContractor's hiring or sub-contracting signature certifies the following: "4 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." --- n f The +cat must call for 011equired i �ctions. C plate drawing on reverse side. r --Title: — r� Signed _-.._—. Date: FOR,DEPARTMENT USE ONLY Application Accepted by Date ( u Area I Pit or Grout Inspection by Date Final Inspection by 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO +.EH13-24(REV.$/H5) .� IRA,3 EH 14-26