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G APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED 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. Job Address R/p ubdivision Name Owner's Name Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ' ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation ' Approx. ❑Eastern" Specifications ❑Cathodic Protection � ^Depth •`� Depth of Grou`fv5ea1 , ❑Geophysical .... _ _ FI Other Type..o f Gr* � Surface Seal Installed by Repair Work Done ❑ Type of.Pump H.P. - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth t` Filler Material (Below 501) TYPE OF SEPTIC 'WDRK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pitpermitted if public sewer is (; Installation will serve: Residence ILavailable within X00 feet.), Commercial _ Other � /�C Number of living units: j Number of bedr oms Lot•size , Character of soil to a depth of 3 feet: 'Water table depth. SEPTIC TANK 1 ❑ Type/Mfg Capacity No. Compartments " PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM { Distance to nearest: Well Fpundation v��9" Property Line DESTRUCTION LEACHING LINE No. & Length of lines `T Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 workman1s 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 compensation laws of California." The applicant must call r a 1� uire spections. Complete drawing on reverse side. Signed X " Title: Date: Date: !-- DEP ENT USE ONLY Application Accepted. by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 5 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by ; Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environma 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE dAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 1 INFO got) 0 r EH 13-24 REV. 10/82 .. 10/82 500 14-26