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r - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 �O PERMIT EXPIRES.1'YEAR FROM DATE ISSUED (Complete in Triplicate) � t 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 i r S� .' City /rLot Size %527/t { Owner's Name Address 2 Phone f i. Contractor • Address License No. Phone f i TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ € PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i i 1 Public ❑ Other f 'pelta Depth of Grout Seal Type of Grout yP t I Irrigation —Approx. Depth I I Eastern ; Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done _ f Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence— Commercial— OtherJ�— Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Weil 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requ'red inspections. Complete drawing on reverse side. Signed X Title: Date: PARTMENT USE ONLY II Application Accepted by l Data � LJ� cArea Pit or Grout Inspection by� Date Final Inspection by Date Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca H23-7104 ❑ 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 C RECEIVED BY ' DATE PERMiT'NO. INFO ASH +.EH 1324(REV.t i w si 0 / EH 14-28 f 'v v ro�tl