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APPLICATION FOR PERMIT 4v\" SAN JOAQUIN LOCAL HEALTH DISTRICT Jvv 1 3601 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address�0 Cit � Lot Size PM I '� Owner's Nam _ Address Phone� — r Contracta vAddress �� "� License iVo. Phone TYPE OF WELL/PUMP: L NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l 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 ❑ Public I-1 Other ❑ Delta Depth of Grout Seal 542 Type of Grout I I Irrigation ___-..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. . State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:" NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments J 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 i SEEPAGE PITS l 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 D,%trict. 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 follow( : "1 certify that in the per( mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of Cali a." The applicant muall for all requir d ' ns. Cdtnplete drawing on,r se side. Sign Title: Date: rK/ FO E T SE ONLY Application Accepted by Date ` -/ Area Inspection b Date Pit or Grout Inspection by Date Final Ins p y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 95201 FEE AMOUNT DUE AMOUNT REMITTED I 4LKip 1 . RECEIVED BY DATE PERMIT'N0. INFO CASH ♦,EH 1 -21(REV.tin51 EH 144-26 �S . C�O 14hu'lo � J l