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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c ' Job Address �] V ' � �L`� — City Lot Size PM Owner's Name , s Phone Contractor q ess 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. 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 F .O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casirig Specifications I'1 Public 11 Other I�'' Cl Delta Depth of Grout Seal 1 qpe of Grout --- I I Irrigation —.-Appr(??x. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth �!' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION E-I DESTRUCTION I I (No septic system permitted if public sewer is V J • available within 200 feet.) f Installation will serve: Residence -J Commercial'_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK'r ❑ Type/Mfg�• Capacity No. Compartments i. PKG. TREATMENT PLT. ❑ i Method of Disposal Distance,to nearest: Well Foundation Property Line .w . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED __LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS o Distanceto nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .16 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 signattire 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 td 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,1 shall employ persons subject to workman's compensa- tion laws of California." " I II The applicant must call for all required inspections. Complete drawing on reverse side. Signed X :'. Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Date i r Additional Comments: �� 1 –'.. ,a. --► �� ❑ Stk 466-6781 ❑ Lodi 36913621 ❑ kftnteca 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 k FEE AMOUNT DUE I AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦ EH 13-24 iREV. EH 14-26 p