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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r 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/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Ci Lot Size PM � I Owner's Name ! ddress Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELI EPI AIAMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OT LL PITS/SUMPS INTENDED USE TYPE OF WELL P EA m.,CONSTR SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca * a Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing ' # pecifications Public ❑ Other ❑ Delta Depth of:Grout Seal Type of Grout ' I I Irrigation pprox. Depth „I I Eastern Surface Seai Installed by _ Repair Work Done ❑ Type of Pump H.P. State Works Done _ Well Destruction ❑ Well Diameter ` Sealing Material Itop 50'1' Depth I Filler Material (Below 50'I A TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTID INo'septic sysjem permitted if public sewer is available withu,200 feet.] Installation will serve: Residence_ Commercial_ Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth t SEPTIC TANK ❑ T Vpe/Mf g Capacity No. C mpartments �+ PKG. TREATMENT PLT. ❑ Method af:Disposal Distance to nearest' Well Foundation Property Liner- i LEACHING LINE ❑ No. & Length of lines f _i `Total length/size G i FILTER BED ❑ Distance to nearest; �Weil Foundation Property Line 760 SEEPAGE PITS I I Depth Size Number V ineDISUMPS ❑ Distance to nearest`: Well Foundation Property Line-,- DISPOSAL SPOSAL PONDS ❑ ; hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San-Joaquin Local Health District. "✓ A li Home owner or licensed agent's si nature certifies the 00— '1 � ma g g g: "I certify that in the performance of the work fortwhicti this permit is issued, 1 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 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." y, j The app ca =callII r W inspections. Complete drawing on r verse side. j. I I Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date f Area/ i Pit or Grout Inspection Date Final Inspection by a Date Additional Comments: W- ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 II FEE INFO AMOUNT DUE AMOUNT REMITTEDC H RECEIVED BY DATE PERMIT'NO. ♦ EH13.24(REV.I/n5) uLJ 3�. Vl� ��-- —07q EH 14-26