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APPLICATION FOR PERMIT 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) Application is he+eby made to the San oaquin Local Health District or 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_ell'pump and the Rules and Regulations of the San Joaquin Local Health District. � r City Lot Size PM Job Address40 � ff Owner's Name h Address � � Phone r _ Address � bP i� ` T Lic6nse,N6' Phone Add Contractor _ - -. - — _----- -- -"' TYPE OF WELLIPUMP: NEW WELL F] WELL REPLACEMENT El DESTRUCTION El PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER El 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 C1 Industrial El Open Bottom C1 Manteca Dia. of Well Excavation Dia, of Well Casing [ ❑ Domestic/Private ❑ Specifications Pack ❑ Tracy Type of Casing P - I ["1 Public ( 1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth l I Eastern ,-5urface.Sealnstalled by H p State Work bone r Repair Work Done [3 Type of Pump , s Well Destruction LlWell Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I (No septic system permitted if public sewer is N r 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: 4 - Water table depth Ca acity No. Compartments SEPTIC TANK ❑ Type/Mfg p PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .F Property Line 1 - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' ".Property Line SEEPAGE PITS I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS. ❑ I hereby certify that t 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 Di'Mrict. Home owner or licensed agent's signature certifies the following: / certify that inhe performance-of-the-work-for-which this permit is issued, I shat[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, I shall employ persons subject to workman's compensa- tion laws of California Theapplic ust call f r all require ins ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date Area 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 CASH RECEIVED BY DATE PERMIT'NO. INFO EH 13$4/REV.i/a s+ EH 1428 r [ a+e