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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 (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/purnp anti the Rules and Regulations of the San Joaquin Local Health District. 1u� � ye�/ Jab Address City Lot Size PM Owner's Name Address Phone Contractor Address _C2.5 a(., _ �( License N1_? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS ❑ Industrial 7Gravel m ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private acy Type of Casing Specifications 71 Public F ❑ Delta Depth of Grout Seal Type of Grout _. I Irrigation Depth I I Eastern Surface Seal installed by Repair Work Done L7 ype of Pump H.P. State Work Done_ •, Well Destructs ❑ Well Diameter Sealing Material Itop 50'1 �l Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTIO Na 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEP ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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 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 applicantt call for all required ins ctions. Complete drawing on r verse side. Signed Title: J Date: FOR DEPARTMENT USE ONLY "] Application Accepted by Date G Area Pit or Grout Inspecti Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ odi 369- 1 ❑ Menteca 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. . EH 13-24 �!rREV.iin5i 3J b c? ?_c act EH 14-28 C J�