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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iComplete 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 City Lot Size PM ROwner's Name ddress Phone Contractor i4' Address !O License No. Phone_ TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CO _TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I El Domestic/ ❑ Gravel Pack ❑ y Type of Casing Specifications M Public Cl Other F1 Delta Depth of Grout Seal Type of Grout _ I I irrigation A Depth I I Eastern Surface Seal Installed by Repair Work Done ype of Pump H-P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material (top 501 Depth f=iller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.I " Installation will serve: Residence— Commercial— Other .\ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: lk Water table depth SEPTIC TANK Type/Mfg' Capacity 4 No. Compartments 01 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation, Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well i Foundation ! Property Line DISPOSAL PONDS ❑ R 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,1 shall employ persons subject to workman's compensa- tion laws of California." , The applicant must call for all required inspections. Complete drawing on reverse side. �L Signed X Title: C Date: FOR DEPARTMENT USE ONLY Q Application Accepted by Date ' u Area Pit or Grout Inspection Date Final Inspection by. ' Additional Comments: / v ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 RECEIVEDBY DATE PERMIT NO. + EH13-24 IREV,t i x 5) ~ Cl EH 14-28 - - l �J L► ,