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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t 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 Loc Health District. Job Address �� _ !��" � ity == Sot Size _( �( � PM Owner s Name �� Jl u�I Address ` Phone � - Contractor G Address' License No. Phone_ TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT 06WELL 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 1-1 Public ❑ Other �+' Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Apprp Depth i I Eastern + Surface Seal Installed by _ Repair Work Done LI_ -Type of Pump H.P. State-Work Done _ l Well Destruction ❑ Well Diameter Sealing Material stop 50') fes. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTIO 1 INo 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. ❑ Method of Disposal r Distance to nearest: Well foundation w 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 Cl 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 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 nI 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 o a�fo►nia." The applic nt us II for r ns tions. Complete drawing on reverse side. 7 igned Title: �� IdLY/� Date: J FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area t Pit or Grout Inspection by Date Final Inspection by Date VP ditionsi Comments: Ok E] �� oStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201��`_�y�/ IFEE NFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMITNO. SS + EH 13-241REV.v/n51 _1r7 r EH14-26 �..I