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r .. 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 he+eby 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 r Local Health District, Job Address' ' City Lot Size Address * Phone V � � Owner's Name k Contractor 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 f FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS `— 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 Cl Other ❑ Delta Depth of Grout Seal y 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 i Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material iBelo ') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION lir DESTRUCTION I 1 -(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms !P, k Character of soil to a depth of 3 feet. /Water table depth SEPTIC TANK ❑ Type/MfgCapacity - No. Compartments {' PKG. TREATMENT PLT- ❑ Method o Di sal Distance to nearest: Well/y_...._ FoundationyA Property Line LEACHING LINE ❑ No:-& Length-of-lines-),=� Total length/size :f FILTER BED ❑ Distance to nearest: Well Foundation lo?-,/ Property Line ' ~ SEEPAGE PITS isl..�Depth ize Number UMPS # L-! - Distance to nearest: Well -._ _ Foundation___ — Property Line r SPOSAL PONDS . ❑ hereby certify that'l 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 parson 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 compansa- n k tion laws of California_" The applicant ust for all requi d i spections. C plate drawing on reverse side. Signed Title: Date: o FOR DEPARTMENT USE ONLY k / Application Accepted by Date 7 Area Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CASH RECEIVED BY DATE PERMIT-NO, INFO I a.EH 13-24 IREV.t/H 51 I EH 14-26