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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. 1B62 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 'fires ense No.12 Yz-- Phone O TYPE OF WELL P M : NEW WILL ❑ WELL REPLACEMENT C 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 ElIndustrial 0 Open Bottom IDManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ..L1 Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation ___-.,Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑, Type of Pump H-P. State Work Done T a, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALL TION REPAIR/ADDITION l I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resid nce 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 Capacity No. Compartments PKG. TREATMENT PLT- ❑ 1 Method of Disposal Distance to nearest: Well p- Foundation�IL_ Property Line LEACHING LEACHING LINE No. & Length of lines T9.tal length/size Ne FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I "Depth Size Number SUMPS Ll Distance to nearest: Weil Foundation 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 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." Contractors 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 applican t all re ed i ns. omplete dr ng rev rse side. Signed Title: Date: FOR DEP TMENT USE ONLY 7 . . Application Accepted by > Date Area � ? Pit or Grout Inspection by Date Final inspection by Date_ - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO GASH a EH 13-241REV.1/A 5) EH 14-2e