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i 1 APPLICATION FOR PERMIT leu'' _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) alth District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local He No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. L%'�'" –` 74E&O�Q� City Lot Size PM I Job Address Owner's Name J � Address / t Phone Contractor (� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT ❑ DESTRUCTION ❑ PUMP iNSTALLAT.0 ❑ SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T e of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack D Tracy Type g ❑ Other [ 1 Det epth of Grout Seal Type of Grout FI 1 Public �~ I i Irrigation —.-Approx. Depth --J-I' astern Su ace Seal Installed S k + H p State Work Done s Repair Work Done ❑ Type of Pump 1 Well Destruction ❑ Well Diameter Sealing Material Itop•501 1 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION 1 DESTRUCTIONA allo septic ailable system m rented if public sewer is r l Installation will serve: Residence— Commercial— Other CI) I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line c. ! LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS F I Depth Size Number SUMPS ❑ 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 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 applic t must call for all re uired inspections. Complete drawing ori reverse side. � Signed Title: _ '' f/ Date: > { FOR DEPARTMENT USE ONLY k Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: e 0 [D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 41, W � 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 + EH 13-24 1 REV.1/8 51 � EF1 14-29 1