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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 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. r r Job Address City Lot Size PM Owner's Name Address Phone Contractor icense No Phone TYPE OF WELL/ U P: NEW WELL ElWELL REPLACEM€NT ❑ DESTRUCTION IM PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t 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 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing Specifications 3^ — n Public F1Other I l Delta Depth of Grout Seal Type of Grout I I lrrigation —.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 Itop 501 +'6 } Depth Filler erial IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR DDITIO E I ESTRUCTION I 1 INo septic,system permitted if public sewer is available within 200,feett.l Installation will serve: Reside c-e "Commereial Other f Number of living units�,,�rooms tl ti �. 'character of soil to a depth of 3 feet:_ "' f �� Water tabl depth SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments r PKG. TREATMENT PLT. ❑ .. Method of isposal Dt ii'istance to nearest: Well &CoFoundation .._..._ Property Line -� .�.. .. �t LEACHING LIN ❑ No. & Length of lines "'� Tota!�engthlsize - ' FILTER BED ❑ Distance to nearest: We11�.�_ Foundation Property Line SEEPAGE PITS I 1 Depth � Number la�U11�+ Cl Distance to nearest: Weil _ Foundation D� Property Line I 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 taws 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 st nall or all required rns cons. Complete dr �ng on eve side. Signed Tite: Date: ( FOR DEPARTMENT USE ONLY Application Accepted by ,y/� Date - Area Grout Inspection by Date � Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 �(J_ w Applicant - Return all copies to: Environmental Health Permit/Services.1601 E...Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �l I FEE AMOUNT DUE AMOUNT REMITTED CK y y RECEIVED BY DATE PERMIT'NO. INFO C,d'SH' + EH 13-24(REV i/N51 Q g EH 1 -29 y -