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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 TYEAR FROM DATE ISSUED v (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. r s /d City t Size PM Job Address Owner's Name Address _ _ Phone Contractor rens &"gicense Nv. Phone–IN-0 r OF WEL IPU NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ PUMP INSTALLATION ElSYSTEM REPAIR ❑,� a OTHER ❑ DISTANCE TO NEAR PTIC TANK- s SEWER LINES _ DISPOSAL FLD. PROP, LINE FOUND `• AGRICULTURE WELL OTHEk WELL PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing 17 Domestic/Private El Gravel Pack ❑ Tracy Type o n - M. Specifications ❑ Public ❑ Other Ci Delta Depth of Grout Se Type of Grout . I Irrigation --Approx. Depth i 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 R - Depth Filler Material lBel 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 RE PAIRIADDITION DESTRUCTION I I (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: c. Water table depth SEPTIC TANK ❑ Type/Mfg., Capacity No. Compartments PKG. TREATMENT PLT. ❑ t t Method of Disposal A Distance to nearest: Well Foundation -—'Property Line LEACHING LINE ❑ No. & Length of lines. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS - 1.1 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. l 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." A The applicantst for all re uire ins ctions. Complete rawing o e e side. ` f Signed X Title: Date: FO DEPARTMENT USE ONLY Chi Application Accepted by Date �r`� 0 U A a Pit or Grout Inspection by Date Final Inspection by 9_ Date Comments:o C Additional . ❑ 5tk nal 781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., f.0. Box 2009, Stk., CA 952111 FEE 4AMEOUNTDU AMOUNT REMITTED CASH RECEIVED BYDATE PERMIT'NO. EH 1&24 iREV.I/H 51 EH 14-26 k