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APPLICATION FOR PERMIT f 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 heteby 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- 5 Local Health District. grt Job Addres6�� City Lot Size 8 ' Address Phone Owner's Name kf hone/ Contractor_ Add resg�,7 License No TYPE OF WELL/PUMP: NEW WELL P-" WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Bim— SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES . DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � el ❑ Industrial pen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 9?1(omestic/Private El Gravel Pack ❑ Tracy }Type of Casing Specifications f� C"1 Public Cl Ot�rer Cl Delta Depth of Grout Seal Type o r t _ I I lrri�jation aw_Approx. Dept I I astern Surface Seal Installed by, Repair Work Done ❑ Type of Pump., ° H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i . e Depth Filler Material {Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i.l OFSTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) ' r Installation will serve: Residence— Commercial_ Other N +� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: x ` Water table depth I _ � s SEPTIC-TANK ElType/Mfg Capacity s No. Compartment a �+ ' Y a Method of Disposal PKG.,TREATMENT PLT:❑-_ - Distance to nearest: Well s Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation : � Property Line II k SEEPAGE PITS I I Depth Size Number SUMPS L1 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 ' �y �• rules and regulations of the San Joaquin Local Health District. 4 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 lis issued,I shall employ persons subject to workman's compensa- tion laws of California." 1.011 The applicant must call for ail required inspections. omplete drawing on reverse side. 01 4 x` J Signed X Title: Date: FOR DEPARTMENT USE ONLY fi Application Accepted by I Date , Arree�a Pit or Grout Inspection by c Date r4— Final Final inspection by (95 ✓ Date Jr : Additional Comments:, ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. INFO 9 y t + EH 13-24 1REv.1/H 57V1 g EH 14-28 Q�, C>