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M 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 incompliance with San Joaquin County Ordinance No. 54 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin Local Health District, p�}� Job Address City Lot Sizt PM Owner's Name Address Phone Contractor. Address License No �� Phone w ^,i TYPE OF WELL/PUMP`. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE :IM FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public LI Other f-] Delta Depth of Grout Seal Type of Grout Y 1 1 Irrigation --Approx. Depth I i Eastern Surface Seal Installed by Or{ Repair Work Done ❑1 Type of Pump H.P. State Work Done _ 1 Well Destruction ❑� Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is r I available within 200 feet.l /p Installation will serve: Residence L Commercial_ Other l Number of living units: Number of bedrooms (3 Characterof soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well 100-4L-Foundation Property Line 6FO - .{ 1. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foun ation a Property Ling-, SEEPAGE PITS r I I Depth Size Number SUMPS 0 Distance to nearest: Well yy Foundation Property Line f DISPOSAL PONDS I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, and t 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:i'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.h �'� The applicant ust call for a uired pedtions. Compl a drawing o reverse side. 7 Signed X Title: Date N a FOR DEPARTMENT USE ONLY Application Accepted .� MIA Date �� S 4I Area - or Grout Inspection by Final Inspection by to `' C Additional Comments'' ❑ 5tk 466:6781 I ❑ Lodi 369-3621 ❑ Manteca 823-7144 C1 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 I� AMOUNT_DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII'T"NO. + EH 13-24{REV.i i n 51 � /��` EH 14-28 i