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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.TON AVE., STOCKTON, CA Telephohe (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 Ad— City Lot Size OL PM Owner's Name �- 11'f Address Phone Contractor �� Address icense leo. 'Phon�(� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl 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 ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of'Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR lADDITION,f'•'DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 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 (� SEPTIC TANK ❑ Type/Mfg G - Capacity No. Compartments _2r PKG. TREATMENT PLT. ❑ r—a r Method of Disposal C lot Distance to nearest: Well Foundation / 6 Property Line--b LEACHING LINE ❑ No. & Length of lines ��TQ Toth length/size FILTER BED ❑ Distance to nearest: Well J 7 Foundation Property Line 1 r SEEPAGE PITS I 1 Depth Z,�.� _Size Number SUMPS Ll Distance to nearest: Well 1W t Foundation .�''Z� f Property Litre 7 DISPOSAL PONDS ❑ t 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 subcontracting 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." The applicant II for ' d inspections. Complete drawing on reverse side. Signed X --& Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area It or Grout Inspection by =3669-362 Date Final Inspection by Date O Additional Comments: ❑ Stk 466-6781 L ❑ Manteca 82317104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \�ok FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ♦. P�Ef(Rwro CASH 57q 4-26 � L EH 13.24(REV. N 5) EH17A`0p `