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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 TYEAR 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. k Jo Address Lot Size PM Owner's N Addres� Phone Contract Addre — License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED..USEs�N ..- ,.-TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ATIONS ❑ Industrial pen Bottom F1 Manteca Dia. o xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑-Tracy Y�' - --•ype of Casing- -- - — Specifications N f"1 Public Cl Other e to Depth of Grout Seal Type'of Grout _ I Irrigation ._._.._.AP epth I.) Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump i H.P. State Work Done _ Well Ir' ❑ Well Diameter I Sealing Material (top 50'1 ' Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DfSTRUCTI I a septic system permitted if public sewer is y L. available within 200 feet.) installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms 'K h Character of soil to a depth of 3 feet: -� f Water table depth SEPTIC TANK ❑ Type/Mfg `. Capacity No. Compartments PKG. TREATMENT PLT. ❑ - ----- Method of Disposal Distance to nearest: Well Foundation Property Line t 1 f LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest:. Well Foundation Property Line ` r i SEEPAGE PITS I I Depth t Size Number SUMPS ❑ Distance to nearest:t Well Foundation Property Line"'" DISPOSAL PONDS Cl ; 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 stibject 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- E.tion laws of California." The applican ust call for all requir d inspections. Complete drawing on r r "de. w Si d X r Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z- Area Pit or Grout inspection by Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-6781 L di 369-3 1 ❑ 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH -EH 6-24(REV,1/H 51 EH 14-26 1