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C Lec y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601•E. _HAZEL T ON AVE., STOCKTON, CA �! r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r _ _ "A „,, (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 x 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 + r �J " City Lot Size PM Owner's Nam %• Address I Phone V Contractor Address .. U T ' Li cense 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 EI Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation Dia. of Well Casing i Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �- Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is V I available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth'of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line j 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. Homeowner 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 1that-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." The applicant must call for all quired inspections. Complete drawing on reverse side. i Signed Title: i Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area Pit or Grout Inspection Date Final Inspection byI Date D 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 LVManteca 623464 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED BY DATE PERMIT'tJO. INFO CA + EH 14-26(REV.5JH5)