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to 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 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 Owner's Name Address Phone Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION INTENDED USE ❑ Industrial ❑ Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack ❑ Other ---Approx. Depth Type of Pump Well Diameter Depth License No. Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal ❑ Eastern Surface Seal Installed by H. P. State Work Done Sealing Material (top 501 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DES! Dia. of Well Casing Specifications Type of Grout c system permits within 200 feet.) Installation will serve: Residence _–A Commercial _ Other Number of living units: _.__ Number of bedroo%s o Character of soil to a depth of 3 feet: n Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundation Property Line LEACHING LINE 'X No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total Property Line if public sewer is W SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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: "1 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 st all for all rregjuiredi ction Complete drawing on reverse side. Signed X Title: Date: FOR DEPAR ENT USE ONLY Application Accepted by f Date//—/,?-4,VArea 4?3 Pit or Grout Inspection by Date oJK Final Inspection by Date 4 G y 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 + EH 1324 (REV. 10/83', EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CSH RECEIVED BY DATE PERMIT" N0.