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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 SA1`� �`� 6 0 City .0 Lot Size C-�C� PM ^– Owner's Name `Address Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ "'� n. SYSTEM REPAIR '❑ 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.i PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA f CONSTRUCTION SPECIFICATIONS �3 y ❑ Industrial ❑ Open Bottom ❑ Manteca •---Dia--of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 11 Other F] Delta Depth.of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surf ace'Seal Installed by _ -Repair Work Done 0 Type of Pump H.P. � State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I'i DESTRUCTION-1 1 iNo septic system permitted if public sewer is / 'available within 200 feet.) Installation will serve: Residence✓ Commercial Other Number of living units: __�— Number of bedrooms �� t Character of soil to a depth of 3 feet: Nbint. e Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 0 14C No. Compartments PKG, TREATMENT PLT. ❑ 1 + Method of-Disppo'al Distance to nearest: Well�� Foundation u Property Line, �1 t oe LEACHING LINE L�YNo. & Length of lines d Q� Total length/size FILTER BED 64--Distance to nearest: Well 1 S13 Foundation �O �— Property Line~ SEEPAGE PITS t I Depth Size _.Number y 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. t 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." i'y The applicant st cal[for all required inspections. Complete drawing on reverse side. Signed X h .lNJ. Title: Date: S- t FOR DEPARTMENT USE ONLY Application Accepted by ��C__- t1nw � ft--1 Date Areay Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑'Lodi 369-3621 % 42❑ Manteca 623-7104 '❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ppPER MIT"NO. * EH 13-24 EH14-2e1AEV.F/Hsi MO