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n APPLICATION FOR PERMIT q SAN JOAQUIN LOCAL HEALTH DISTRICT !gyps �W 1601 E. HAZE.i ON AVE., STOCKTON, CA Telephone (209) 466-6781 K7J c T"v" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 cam with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin compliance q l Local Health District. Job Address City Lot Size PM Owner's Name _Address, Phone ContractorAddress 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 FOUNDATION AGRICULTURE WELL 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 p 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout \tel 11 Irrigation --Approx. Depth I l Eastern Surface Seal Installed by - V Repair Work Done ❑ Type of Pump H.P. State Work Done [ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION i I DESTRUCTIOfVfN,1No septic system permitted if public sewer is ailable within 200 feet.] t s Installation will serve: Residence_ Commercial_ Other a. Number of living units: Number of bedrooms fit Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line F ; i LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS El Depth Size Number 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 laws, and i rules and regulations of the San Joaquin Local Health District. 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 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 applic st call for all requi inspections. Complete drawing on reverse side. r Signed Title: C9 1_4 � date: ` F R DEPARTMENT USE ONLY t � r Application Accepted by aAA � k , Date ` —9� Area 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 1 ` FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT I'O. 4INFO CASH `p I� f EH 1 � �,�� 3�� ///I�/J/ !/ /4j O> /'�� . - .