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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 sewageorNo. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address •t PhoneZ2 3 Contracto /Y✓ L >r )r AddressLicense No. �phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,,A< OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SlJMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom IY Manteca Dia. of Well Excavation Dia. of Wet Casing ^,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other ❑ Delta Depth of Grout Sea! I I Irrigation __Approx, Depth I I Eastern Surface Seal Installed by Type of Grout _ Repair Work Done ❑ Type of Pump H.P. State Work one Wel! Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I_1 REPAIR/AUDITION I I DFSTRUCTlON I 1 INo septic system permitted if public sewer is available within 200 feet) Installation will servo: Residence Commercial Other Number of living units: Number of bedrooms V 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 r LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation '7 Property Line ! i SEEPAGE PITS l 1 Depth Size _ Number SUMPS' - ❑ 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 rules and regulations of the San Joaquin Local Health Dt%trict. 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 per on in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f to certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion law s of ali rnia." The appli n ust call for all eq red ins ions. Complete drawingC e e sic . Signed X Title: Date: FOR DEPART E USE ONLY �} 04 Application Accepted by 'n° Zr' F' Area Date 1 ea Pit or Grout Inspection by Date Final Inspection b Dat OA Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 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 INFO CASH— RECEIVED BY DATE PERMIT-NO. + EH 13-24 1 REV.s i x 51 EH 14-26 1 `J Q�t