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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1wori 1601 E. HAZELtON AVE., STOCKTON, CATelephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATEISSUED(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the is application is made in compliance with San Joqu Co ty Ordin�ajAa No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. {} City N Lot Si;e PM Joh Address Owner's Name .Flit=– Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ MP INSTALLATION ❑ SYSTEM IR C] OTHER ❑ ttd^ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SE TANK SEWER LINES FOUNDA AGRICULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO LEMARfiX CONSTRUCTION SPECIFICATIONS p Industrial ❑ Open"Bottom t Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications F1 Public ❑ Other _ Delta Depth of Grout Seal Type of Grout 1 l Irrigation --Approx. De 4 I Eastern Su a Seal Installed by Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well Diam ter Sealing Material (top 501 .� Depth Filler Material {Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION Mo septic systhin m permitted if public sewer is 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 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 Number SEEPAGE SEEPAGE PITS l I Depth Size SUMPS Ll 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 rules and regulations of the San Joaquin Local Health Di%trict. "I certify 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: 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 applicatAcce"Piied ll re uired ins actions. Complata drawing on reverse sides. Cy/ Signed X Title: � p r _ Date: FOR DEPARTMENT USE ONLY Date � Area 5 Application Pit or Grou Date Final Inspection by � Date Additional Comments:' } t 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O.`Box 2009, S1k., Co /I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERIND.INFO (�� y jEH 13-24IREV.I IK5) , _INM L'f ��' EH 14.26