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E APPLICATION FOR PERMIT [ SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (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. r t,Size _.PM Job Address / r�/ "� City �a - Owner's Name Address Phone { Contractor Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 9�^ a. I 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 ` L3Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LJGravel Pack ElTracy Type of Casing Specifications r ! ('l Public Cl Other {l Delta Depth of Grout Seal Type of Grout FI I Irrigation —Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Pones Well Destruction . Well Diameter rr �_ Sealing Material (top 501 d Depth Filler Material (Below 501 — a TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIWADDITION l I DESTRUCTION l I IN septic.system.permitted it public sewer is f available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth rl r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . Property Line t!L LEACHING LINE ❑ No. & Length of lines Total length/size I{t FILTER BED ❑ Distance to nearest: Well Foundation Property Line (f� F SEEPAGE PITS I I Depth Size — Number l% SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. 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, 1 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." The applicant must call for all required inspectionsj inspectionCowfilete drawing on reverse side. I Signed X Title: Date: 4 FOR DEPARTMENT USE ONLY i Application Accepted by Date ( �Y Area Pit or Grout Inspection by Date Final Inspection In _ Date I �f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca BM-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 �(z g ' r.EH 13-24(REV. 3 5-co 357, a0 r�-rJ �0"1�— • �Sy �. EH 14-26