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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON,-CA d Telephone (209) 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. s Job Address L City Lot Size PM �_ ,. Owner's Name Address Phone i Contractor Address License filo. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS 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 FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth 1 I Eastern -=Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Ito _ (r Well Destruction ❑ Well Diameter,_ Sealing Material p 50'1 �1 Depth I Filler Material IBelow 50') — f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTIONalvo septic lable system m emitted if public sewer is eet f Installation will serve: Residence_ Commercial_ Other _ I , I Number of living units: Number of bedrooms { q Character of soil to a depth of 3 feet: Water table depth Il SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments E PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property.Line ` LEACHING LINE LI No. & Length of lines Total len gth/size FILTER BED ❑ Distance 4o nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl 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 DiMrict. 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 California Contractor's hiring or sub-contracting signature certifies the follow g:" certify that' he performa of i work for which this per ' is issued, I shall employ persons subject to workman's compensa- F tion laws of Calif rnia." The applican t I for all c io s. Co pl-ete drawing on reverse rde. Sig d X_ Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date "^-2 -L& Area i 1 Pit or Grout Inspection by Date Final Inspection by�� _� = Date/'O d Additional Comments: ❑ Slk 466-6781 ❑ Lodi 369-3621 ❑ Manteca M-7104 ❑ Tracy 835-6385 Mn Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED KSH RECEIVED BY DATE PERMIT NO. i INFO ..EH 13-24(REV.i i H sl 3 0 Is LA EH 14-2(1