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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job4ddress City� Lot Size �a PM Owner's Name �Oy` e1+� Address Phone a S Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ y WELL REPLACEMENT ❑ DESTRUCTION ❑ UMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca la. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications F] Public Ll Other Cl Delta Depth of Grout Seal Type of Grout ,.. I i Irrigation prox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done Type of Pump H.P. State Work Done Well Destr ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION l' (No septic system permitted if public sewer is } I N available within 200 feet.) 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I 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 . 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 applicant-must call for al uir d inspe s. Complete drawing on reverse side. +y .,Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 2/4 Area i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:y ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERIVI T'NO. L + EH 13-24(REV,I/H5) �r.VU 3�r�� i �r EH 14-26 �] y ✓ 1