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APPLICATION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 1 Cit of Size PM Job Address f Phone ' Owner's Name s 4 ` f Contractor s se No, Phone TYPE OF WE L/PU P: NEW WE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1:1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EJ industrial LJ Open Bottom ❑ Manteca Dia. of WeII Excavation Dia. of Well Casing LlDOmeStIC/PFlvate L1 Gravel Pack O Tracy Type of CasingSpecifications FI Public ❑ Other ❑ Delta Depth of Grout Seal P Type of Grout I 1 Irrigation _..Approx. Depth l I Eastern Surface Seal lnstaNad by i Repair Work Done ❑i Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material (top 50'1 — Depth I Filler Material .(Belo i TYPE OF SEPTIC WORK:, NEW INSTALLATION [-1 REPAIRIADDITION ( DESTRUCTION { I (No septic system permitted if public sewer is r available within 200 feet-) Installation will serve: Residence— Commercial Other I � .. Number of living units: _J_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � I ..- r y LEACHING LINE ❑ No. & Length of lines Total length/size 1 E FILTER BED El Distance to nearest: Well Foundations_.— Property Line f SEEPAGE PITS ( I Depth -Size., Number SUMPS L-1Distanceto nearest:1 Well Foundation Y Property Line. y DISPOSAL PONDS ❑ : f 1 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 r 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust or all repo' in actions. CompJorp drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY plication Accepted by date Area Pit r Grout Inspection by Date r incl Inspection by Date/ L-S M Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 REMITTEDCgSH RECEIVED BY DATE PERMIT'NO. INFO I { +.EH 13-24 IREV.v K sr - —A-W t F EH 1428