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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT t 1601 E. HAZE 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 I Local Health District. a Job Address v S` City Lot Size x s� PM Owner's Name Address O Phone Contractor A dress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 5 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR RE WELLOTH ITS/SU P5 INTENDED USE TYPE OF WELL PROBLEM AREA CO N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavati Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta 3 Depth of Grout Seal Type of Grout ❑ Irrigation ox. Depth ❑ Eastern _ Surface Seat-Installed by Repair Work Done ❑ e of Pump 'r H.P. State Work Done Well Destruction ❑ Well Diameter, Sealing Material (top 50'1 l}3 Depth " ' Filler Material (Below 50') - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No'septic system permitted if public sewer is available within 200 feet.) kA Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V 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 IengtFi/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size j Numberl� SUMPS ❑ Distance to nearest: Well Foundation Property Line S 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:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensate`,, tion laws of California." plicant ust call for qI1 required -Inspecylons. Complete drawing oonn�' reverse side. J Q' Signed Title:�, i_ /J Date: FOR DEPARTMENT USE ONLY _ f Application Accepted by Date Area v Pit or Grout Inspection cDate Final Inspection by Data-J� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8*-- h04 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CSH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 1 REV.L/R 5) 3 EH 14-28