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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL T ON AVE., STOCKTON, CA _ Telephone (209) 466-6781 f 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 City Lot Size PM Owner's Nanw_,_� ��luQ�('OI!Y1_Yl Address a Phone Contractor eJ Z 7— Address License No. Phone_ TYPE OF WELL/PUMP: 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing e ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation __-Approx. Depth 1 ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth ,Filler Material I8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i 1 DESTRUCTION X (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other d 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth Size Number i SUMPS Ll Distance to nearest: Well 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 x rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:g g g: "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." Contractors hiring or sub-contracting signature I 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." i The applicant must call for all required inspections. Complete drawing on reverse side. I� r Signed Title: Date: FOR DEPARTMENT USE ONLY C Application Accepted by Date � Area yt Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 95201 FEE AMOUNT DUE,' ""'AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO" +.EH13-24(REV.t 5) 5 ''�/ 7 /0 EH 14-29 Uy!/ 1