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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 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 ^ 7• f Address , ��f Phone Contractors Name License No. v Phone 15��& 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �- ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 501 C' Depth Filler Material (Below 501 r „ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is O available within 200 feet.) a Installation will serve: Residence_�c Commercial— Other l' Number of living units: —/— Number of bedrooms-12--1 . r� 1 Character of soil to a depth of 3 feet: Water table depth r� [[ SEPTIC TANK ❑ Type/Mfg If Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal F Distance to nearest: Well Foundation' Property Line a l LEACHING LINE ❑ No. & Length of lines r. Total length Isizd FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth .2 -Size 36 Number SUMPS ❑ Distance to nearest: Well Foundation oeO 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 I rules and regulations of the San Joaquin Local Health District. I 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."Contractors hiring or sub-contracting signature L 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 m II f all r quired ins ctio . Complete drawing on reverse side. Signed r Title: Date: FOR DEPARTMENT USE ONLY Q �y Application Accepted by DU 3 Pit or Grout Inspection by Date Y ;Final Inspection Pby Date Additional Comments: �� A O[1 ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 823-7104 [1 Tracy 835- �JQ C e i" 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 CASH RECEIVED BY DATE PERMIT'N0. INFO '} ryv+ ��7( lk�(} + EH 4 4REV.10/831 6 1-u—,EH 13-2 y l�2 V 1 l3