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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT w - 1601 E. HAZE.T ON 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. 4 r t ' ' 1O Jvailt Size PM W � City Job Address y�� Address � Phone Owner's Name �t e I Address License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION 11 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -1Manteca Dia. of Well Excavation Dia. of Well Casing Type Specifications ❑ Domestic/Private � ❑ TGravel Pack ❑ Tracy YP of Casing - ❑ Public Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.-Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 501 V) TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION (-I DESTRUCTION (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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line i 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 District. rt that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I ce mpensation taws California." Contractor's hiring sub-contracting signature employ any person in such manner as to become subject to workman's co + ich this permit is issued, ued,!shall employ persons subject to workman's compen5a cartifies the following: "I certify that in the performance of the work for wh tion laws of California." The applicant must call for all requirelK inspections. Complete drawing on reverse side. I 7 Signed X �' Title: Date: E f FOR DEPARTMENT USE ONLY Application Accepted by Date r Area ata Final inspection by Date I Pit or Grout Inspection by _i _ �� y Additional Comments: `1 / ❑ Stk 466-67131 ❑ Lodi 369-3621 ❑ Manteca M-7104 ❑ Tracy 835.085 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 I CK RECEIVED BY DA;�31 PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED) GASH INFO G:v + EH 13-24 1 REV.I I K 51 _ EH 14-26