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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. e Job Address City L Lot Size PM Owner's Name. A dress Phone Contractor„ t. Address //3 t� r c a Licens/N o. �d S Phone J 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 N ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ro Casing Specifications ^` M Public Cl Other ❑ Delta " Depth of Grout Seal - Type of Grout- _ I I Irrigation .-Approx. Depth I I Eastern. 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 IWORK: NEW INSTALLATION IJ> REPAIR/ADDITION I I DESTRUCTION- (No septic system permitted if public sewer is .; vailable within 200 feet.) Installation wilf:serve: Residence_ Commercial— Other "• I Number of living units: Number of bedrooms * } s Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK ❑ Type/Mfg �.Capacity No. Compartments' - PKG. TREATMENT PLT. ❑ t 4 ; � Method of Disposal q� Distance to nearest: Well Foundation' - Property.1ine s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 'Distance to nearest: Well Foundation + Property Line s SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well _ 'Foundation j. 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 rulesand regulations of the San Joaquin Local Health District. r -Home owner or licensed.agent's•signature-certifies,the following -1 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 applicay2nust call for all required inrections. Complete drawing on reverse side. Signed Q�� Title: aw.,fzd AA� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH FIECEIVER BY /DATE PE�RMIT NtO�. +.EH 13-24(REV.iiHs)