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i APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ry• � a (Complete in Triplicate) r 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.1662 for well/pump and the Rules and Regulations of the San Joaquin' `Local Health District.' Job Address City ��1�°'y " Lot Size PM -Owner's Name Address - Phone t Contractor Address . ate 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 FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTIO NS ❑ Industrial ❑ Open Bottom. .,-.❑-Manteca._ ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing ` Specifications ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout 5 fff ❑ Irrigation I prox. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Don Typ 1 f Pump H.P. State Work Done Well D tion ❑ We1I Diameter —Sealing Material {top 501 f Depth Filler.MatriaI { elow 501 111 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION {No septic system permitted if public sewer is 3vailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms r r Character of soil to a depth of 3 feet: # # i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity g { No. Compartments 1,P,KW-TREATMENT PLT. ❑ t: Method of Disposal Distance to nearest: Well Foundation { Property Line LEACHING LINE ❑ No. & Length of lines ? Total length/size FILTER BED !❑ Distance to nearest:....,_.>Well�-.. ._ ____w Foundation- # j Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property'Line DISPOSAL PONDS ❑ 1 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: f. 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 rm _ this peit is issued,I shall.employ persons subject to workman's compensa- tion laws of California." y The applicant st call for all required inspqctions. Complete drawing on re side. �[ Signed < Title: Date: OR PART ENT USE ONLY 1 Application Accepted by Date ` Area. Pit or Grout Inspection by Date ' Final Inspection by Date,I_._J i Additional Comments: ' LIQ r CJ_J-,v CIc� U lr - y rr ❑ Stk 466.6781 ❑ Lodi 369-3621 t❑ Manteca 623-7104 ❑ Tracy 835-6385 �cr e, ev v Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9& I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY HATE PERMIT'NO. INFO a EH 17-241flEV.1/85) -''•EH 1426 V f ,