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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT ® 1601 E. HAZELTON 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 r City Lot Size PM Owner's Name ► / /� �r' r/ / --- Address 04h, Phone'7'� P�� V Contractor _Address "r License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE C TANK SEWER LINES DISPOSAL FLD- PROP. LINE fOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Botto n eca Dia. o Excavation Dia. of Well Casing t ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifications F1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation Approx.-Depth l 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 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I.I DESTRUCTIO No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residenc Commercial_ Other Number of living units: Number of bedrooms Character of soil to a'depth of 3 feet: 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth -Size Number ! SUMPS L-1 Distance to nearest! 'Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared thissapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i 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, I shall not employ any person in such manner as to become subject t6 cirkman's,compensation taws of California."Contractor's hiring-or sub-contracting signature I certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applic ust call for all required inspections. Complete drawing on rever�se� side. / Signed Title: �f11✓ `" �' ` Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �Z " AreaIF Pit or Grout Inspecti Date Final Inspection by_ ry (/ Date y Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 82 =71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Pe t/.1; 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r INFO CA5H r Eli13-21[REV.sins] ��!/A/ _ - EH 11-26 �(lja`il_