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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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. Job Address A -S— City Moe,e, Size PM Owner's Name "� Address Phone _ Contractor �diQress 0 �L icense No Phone TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT 6r 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 r7 Public r ❑ Other 171 Delta Depth of Grout Seal Type of Grout 1,1 Irrigation -Approx. Depth 1 1 Eastern Surface Seal Installed by ~ _ Repair Work Done ❑ Type of Pump H.P. f - State Work Done Well Destruction ❑ Well Diameter „_Sealing Material (top 501 Depth y Filler-Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I D TRUCTION iNo s tic system permitted if public sewer is avail le within 20D feet) I t Installation will serve:. Residence_ Commercial— Other 1t Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth k SEPTIC'TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ ; '. f Method of Disposal s Distance to nearest.:---,Well Foundation Property Line 'r - LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well' Foundation `"... -J Property Line t SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS. ❑ S hereby certify that! 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. ' 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. 1 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 applica t ca f r all,require 'ns ons. Complete drawing an verse side. Sigi 4 Title: Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date Area ' Pit or Grout Inspection by Dain Final Inspection by Date Additional Comments: o k r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manta823-7104 © acy 835-638 - 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 CK RECEIVED BY DATE PERMIT'No. t.EH 13-241REV.ti n 5 EH 14-26