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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT M' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209). 166-67$1 PERMIT EXPIRES '{'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 ` Address -�` Phone f Contractor Address License No. Phone_ TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIO AGRICULTURE WELL OTHER WELL—PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC N'SPECIFICATIONS ❑ Industrial L] Open Bottom ❑ Manteca Wel Excavation Dia. of Well Casing a ❑ DomesticIPrivate ❑ Gravel Pack Trac Type of Casing Specifications I 7 Public ❑ Other elta Depth of Grout Seal Type of Grout I 1 Irrigation __Appro epth Il Ea rn Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter ling Material (top 501 1! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION I I DESTRUCTION iNo septic system permitted it public sewer is U 11 ",,available within 200 feet.) ( (� Installation will serve:"Residence _ Commercial ,Other �J J Number of living units: Number of bedrooms rl Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK n--Type/Mfg—" Capacity.". No. Compartments PKG. TREATMENT PLT. ❑ _ ' Method of Disposal k - Distance to Larest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth 5lieNumber SUMPS Ll Distance to nearest: Well 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 s6ch 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." I The applicant rrWst Call for all r uired inspections. Complete drawing on reverse side. q ( � w/4—''I/ Date: € X Signed X - Title: w i ' 1 4 FOR DEPARTMENT USE ONLY ,� T k ; r Application Accepted by Date r Area Pit or Grout Inspection by - Dat� nal Inspectign y Date Additional Comments: "D D r O 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 r 1 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY OATS PERIVII7'.rNr7Q. " + EH 13-241REV.I/H5Y ..EH 1428 -