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APPLICATION FOR PERMIT -' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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/of 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 City Lot Size PM Owner's Name Address Phone f Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy R Type of Casingtions [7 Public n Other Ll Delta Depth of Grbut Seal '� Type of Grout _ 1 I I Irrigation Approx. Depth I 1 Eastern -Surface Seal Installed by Repair Work Done C7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION (No 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 CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well —Foundation- F Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well j Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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 employ any person in suc manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin .. ce if at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor Ia.' The applicant mus all uired inspections. Complete drawing on reverse sl e. /w Ix Signed X Title: 10 Date: FOR EPARTME T USE ONLY Application Accepted by Date —a Area Pit or Grout Inspection by Data Final Inspection by Date / Additional Comments: ` �?3 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 ) 't`EH13-24(REV.I/95) ,EH 14-26 �/