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4 APPLICATION FOR PERMIT } � SAN JOAQUIN LOCAL HEALTH DISTRICT �— 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED c (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. i r City of Size PM Job Address C e' Q �f "} Addresso - Phone S Owner's Name r r.� License Na. _ Phone Contractor _Address l TYPE OF WELL/ NEW WELL 0. WELL REPLACEMENT El DESTRUCTION El $ PUMP INSTALLATION`❑ SYSTEM REPAIR ❑ OTHER El �. 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing LS ecifications ❑ Domestic/Private I-] Gravel Pack ❑ Tracy Type of Casing P f"1 Public ❑ Other x F1 Delta Depth of Grout Seal Type of Grout I I Irrigation ,Approx. Depth I 1 Eastern Surface Seal Installed by r H p State Work Done _ Repair Work Done ❑ Type of Pump Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 Y Depth 1 Filler Material (Below-50'-1, r TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION l 1 DESTRUCTION No septic system permitted if public sewer is available within 200 feet-1 k Installation will serve: Residence_ Commercial_ Other Number of living units: l Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Capacity No. Compartments SEPTIC TANK O Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ f n{ Distance to nearest: Well Foundation Property Line e €. LEACHING LINE ❑ No. & Length of lines Total length/size 9 r FILTER BED ❑ Distance to nearest: Well Foundation Property Line • SEEPAGE PITS VI Depth + Size Number SUMPS Ll 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 Iaws, and j 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 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner n 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X � Title: Date: .112 '5��FOfi DEPARTMENT USE ONLY Date Area Application Accepted by y Pit or Grout Inspection by date Final Inspection by t Date Additional Comments; 3 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6365 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 CASH RECEIVED BY HATE PERMIT'NO. INFO ..EH13-24MEV.I/Kai pO o3 Of )I /24 EH 14-26