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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 �5 PERMIT EXPIRES VYEAR FROM DATE ISSU (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h��rplh.�e�criI ed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruled A Ulations of the San Joaquin Local Health District. I `4 Job Addre City �/z��`� Lot Size PM rC Phone Owner's Name j r fat ress i Contractor e Address License No. Phone Phone TYPE OF WELL/PUMP: IGNEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION LJ PUMP INSTALLATION ElSYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFr WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,XPublic ❑ Other I ll Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Degib-, I I Eastern Surface Seal Installed by Repair Work Done .0 Type of Pump - H.P. State Work Done- Well Destruction D Well Diameter Sealing Material (top 50'i Depth 11. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION Ia DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_. Other (� Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. ❑ i�. 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 SEEPAGE PITS I 1 Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4I 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. jHome 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 su nner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: I c ify 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 Califor The applicant mu f all rg Ir spections. Complete drawing on rever e Signed X Title: Date: t/ FOR ARTMENT USE O LY J 4 Application Accepted by , Date �� Area 2 G � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ .. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH -Ih ♦ EH1324(REV.t i x 51 �k4t - EH t4-2a M