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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 h;t descriM. f�,,.Yation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an egulatiooaquin Local Health District. Job Address �1 / City � Lot Size riPM Owner's Name r Address x 1 PhoneTSZ_� Contractor r Address t � License No. Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public ❑ Other ❑ Qelta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Dia Sealing Material (top 50') D Filler Material (Below 501 TYPE OF SEPTIC WORK: W INSTALLATION R/ADDITION I I DESTRUCTION"i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: R�esience Commercial they Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A o. Water table depth SEPTIC TANK 11Type/Mfg +� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispo I Distance to nearest: Well [� Foundation _Z* Property Line Sd LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation _ Property Line SEEPAGE PITS I I Depth 2 Size _ Number _ SUMPS 1_1 Distance to nearest: Well/0-0 4 Foundation AQProperty 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 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 applicant must call for al quired inspections. Complete drawing on reverse side. _ /� r Signed X Title: Q .t . Date: 1`\ FOR DEPARTMENT USE ONLY ` Application Accepted lov v Date �4_ � Area Pit or Grout Inspection y Date Final Inspection by Date .Z Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT NO. a EH 3-24(REV.r/x51 7� EH 14-26 ! ICJ