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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 L� 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. J Addres _ — Lot Size PM i Q Owner's N Address Phon� , Contract 00, Addresss�� ! License Ph��r�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WEL S/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ICATIONS C7 Industrial ❑ Open Bottom a © Manteca pia. Excavation Dia. of Wel] Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing I Specifications M i Public C3 Other t 141 D Depth of Grout Seal P Type of Grout _. I ] Irrigation` __Approx.`D I 1 Eastern Surface Seal Installed by Repair Work Done ❑. Typ ump r H,P. A. {State Work Done Well Destruction Well Diameter ~" Sealing Material-Itop 50'l +_k. Depth � Filler Material (Below 50'1"f I TYPE OF SEPTIC WORK:' NEW INSTALLATION 11.: :ftEPAIRIADDITION I 1 DEST.RIJCTIO. (No septic system permitted if public sewer is q f `y 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. ❑ j r I j r r Method of Disposal Distance to nearest: Well ��Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well ,Foundation Property Line DISPOSAL PONDS ❑ 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 fallowing: "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 vrorkman's com06rMation'laws of C51ifotnia:""Contractor's hiring or sub-contracting signature certifies the fallowing: "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 u t call for all required in ctions. Complete drawing en rem a side. Signed i Titre: y Date: FOR DEPARTMENT USE ONLY Application Accepted by W- Date L> Area Pit or Grout Inspection by Date Final Inspection by t Date Additional Comments- .171 omments:.❑ Stk 466-6781 If Lodi /369-3-621 ❑ Manteca 623-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE O AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. r EH 13.24]REV. i e 51 ( � Wiv EH 14-28