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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s .. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone f209) 466-6781 i 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. City Lot Size PM Job Address Phone Owner's Name Address Address License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q h PUMP INSTALLATION El SYSTEM REPAIR LJ OTHERX S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n� USE TYPE OF WELL 4*ROBLEM AREA�ONSTRUCTION SPECIFICATIONS ),�,INTENDED ndustrial 1❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications 0 Domestic/Private ❑ Gravel Pack CI Tracy YP g I'1 Public fl Other F1 Delta Depth of Grout Seal Type of Grout —. -- I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (:I REPAIR/ADDITION l I DESTRUCTION l 1 INo septic systempermitted if public sewer is available within 200 feet.E Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Water table depth Character of sail to a depth of 3 tee[: SEPTIC TANK (D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E3Method of Disposal Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ Na. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'1 Depth Size — Number SUMPSL-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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 ' The appli cal r all required inspections. Complete drawing on reverse side. Title: tJ Date: Sign X d k F PAR USE ONLY 9 Date 117" � I App(cation Accepted by I ___T- 1pate F'nal Inspection b � � +Date C. l Pit or Grout Inspection by r �!- i i Additional Comments: 835 6385 ,� A Y ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy / 5��" 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 C K RECEIVED BY DATE PERMIT'NO. INFO {� i +.EH13-24(REV.r/Rs) �j S, EH 14-28