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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA (�— Telephone (209) 466-6781 I PERMIT EXPIRES 1`YEAR FROM DATE ISSUED NAB% F 1 (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 �- Address Phone Contractor ` Address License No. "1 Phone TYPE OF WELL/PUMP: NEW WELL E 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI G ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ovation Dia. of Well Casing �^-^;; r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyype of Casing Specifications V l t l Public ❑ Other a Depth of Grout Seal Type of Gout I 1 Irrigation —_Appr pth e i I Eastern Surface Seal Installed by - Repair Work Done ❑ of Pump H-P.-- --— State Work Done _ v Well Destructio Well Diameter ._ Sealing Material (top 50100 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION ((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: Water table depth ` SEPTIC TANK ❑ Type/Mfg re Capacity N No. Compartments *` PKG. TREATMENTPLT. ❑ .- Method of Disposal' w Distance to nearest: Well Foundation Property Line �F 1 LEACHING LINE ❑ No. & Length of lines Total length/size + i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size { Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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. 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 comion pensatlaws 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 Califo 1 The applicant ust or a ins to s. Complete drawing on reverse side. Signed X Title: Date: � MOR DEPARTMENT USE ONLY i' Application Accepted by C1 k_ _— date 7`'� 12,1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 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 REMITTEDCSH RECEIVED BY DATE PERMIT NO. ,,11 + EH13-241REV.iiH57 INFO 0V EH 14-26