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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JComplete in Triplicate) Application is hereby made to the'San Joaquin Local Health District for a permit to construct andlor 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. Job Address Cit Lot Size PM �� f''"�� City Owner's Name Address ^5 Phone Z` Contractor �",, NEW Address License No. Phone TYPE OF WELL/ ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k 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 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C Ll Public I❑ Other C1 Delta Depth of Grout Seal Type of Grout —.Approx. Depth I.1 Eastern Surface Seal Installed by - I I Irrigation State Work Dane Repair Work Done ❑ Type of Pump � H.P. Well Destruction ❑ Well.Diameter Sealing Material (top 501 Depth Filler Material (Below 501 &9W - a TYPE OF SEPTIC WORK: NEWINSTALLATIdN 11 REPAIR/ADDITION l I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) i 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 No. Compartments SEPTIC TANK ❑ Type/Mfg opacity 11Method of Disposal PKG. TREATMENT PLT. Distan arest: Well Foundation Property Line r _ LEACHING LINE ❑ No. & Length'of lines Total length/size FILTER BED © Distance to nearest` Well Foundation Property Line EEPAGkPIITS I I Depth Size Number SUMPS( L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and 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 L 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." s The applicant must 11 for all required inspect' ns. o plete drawing on reverse side. r Signed, Title: Date: -FOR,DEPARTMENT USE ONLY Application Accepted by ��' i�u Date V2 — Area Pit or Grout inspection by Date Final inspection by Date-T--7 Additional Comments: T EI Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante a 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED9H RECEIVED BY DATE PERMIT NO. INFO < y7 +.EH 13-24 iREV.1195) EH 14-26 ,_ _