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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 - City `I Lot Size PM Owner's Name - „/� ' OUff Address Phone Contractor I J Address License Na. Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ C, 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surf a re Seal Installed by s Repair Work DoneType of Pump IA H.P. P 2, State Work Done Well Destruction X Well Diameter Sealing Material Itop 501 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.) 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 Capacity No. Compartments PKG. TREATMENT PLT Q `t" ,"; Method of Disposal '—Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size....i FILTER BED ❑ Distance to nearest: Well Foundation Pro a Line. SEEPAGE PITS ❑ Depth * Size I s Number SUMPS ❑ . Distance to nearest: i Well 4 1 Foundation Property Line DISPOSAL PONDS ❑ # 1, j 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. y 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 compensa- tion laws of California." ' The applicant must call for all requir inspections. omplete drawing on reverse sid . ' Signed Title: Date: / t FOR DEPARTMENT USE ONLY Application Accepted by __— _.....__ Date Area Pit or Grout Inspection by -�' Date Final Inspection by j Date Additional Comments: E3 Stk 466-6781 [Lodi 369-3621 ❑ Manteca 823-7104, L) Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 INFO FEE AMOUNT DUE _ 'AMOUNT REMITTED CK CASH RECEIVED BY OAT PERMIT 0. + EH 3-24(REV.s/n5) �� 43S� /EH 14-213 !(/