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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ND �✓ U -1" 1601 E. HAZELTON AVE., STOCKTON, CA do Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AD A,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 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 City Lot Size PM 0of _9 Owner's Name "1C/ Address Phone Contractor =8s se No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 0C Depth Filler Material (Below 501 TYPE O IC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sews is available within 200 feet.) Installation will serve: esidence_ Commercial__-_ Other Number of living units: Number of bedrooms Character of soil to a depth of t, Water table T SEPTIC TANK ElType/Mfg Capacity No. partments 01 PKG. TREATMENT PLT. ❑ ethod of Disposal {� Distance to nearest: Wel Foundation Property Line ?� r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well __ Foundation Property Line SEEPAGE PITS 11 Depth Size __ _ Number_ SUMPS Cstance to nearest: Well Foundation Property Line _ DISPOSAL PO ❑ lyereKcertify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance-&—state laws, and (lules and regulations of the San Joaquin Local Health Diktrict. 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, I shall employ persons subject to workman's compensa- tion laws of California." The applica r all a it din ons. Complete)ra l on reverse side. Signed X tle: Date: _ FO DEPARTMENT USE ONLY Application Accepted by t- Date Area . Pit or Grout Inspection by Date Final Inspection by Date —30- 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 CKRECEIVED BY DATE PERMIT NO. INFO CASH 2. +,EH13-24(REV.1/85) EH 14-2e