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APPLICATION FOR PERMIT -A 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 1 1 Subdivision Name Owner's Name Address Phone Contractor's Name License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.- DISPOSAL FED. PROP. LINE ' FOUNDATION ��AGRICULTURENELL" '`� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -^- ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack TracR - ! __Dia of=W0 1-Casin�` ❑ Public ❑Other ❑ Delta 4 "Type of Casing Irrigation Approx. E] EasternerSpecifications = ^` Cathodic Protection Depth �t ElCathodicy.' Depth of Grout Seal Geophysical j- �,� 1%, Type of Grout r>r U Other Surface Seal Installed by Repair Work Done ❑ -Type of Pump H.P. r` State Work Done Well. Destruction ❑f Well Diameter Sealing Material' (top 50') ~ h' Depth Y Filler Material. (Below 50') TYPE OF SEPTIC WORK: NEW INSTRLLRTION ❑ REPAIR/ADDITION ❑ (Na septic tank or`seepage pit permitted if public sewer is r -` available within 200 feet:) Installation will serve: Residence Commercial Other -Number of living units: Number of bedrooms Lot size y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ~' PKG. TREATMENT PLT. (] Type/Mfg "s Capacity ` Method olf Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION "_'; 71 LEACHING LINE ❑ No. & Length of lines ' Total length/size -FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth „Size Number — _Q�stanc.e .to.nearest,_Well Foundation.- Property_Line mm � 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 shallnot employ any person in such manner as to become subject to workmans compensation laws of California." ` Contractor's hiring or sub'-contracting signature certifies the following: "I certi-fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." A The applicant must call for all required inspections. Complete drawing on reverse side. Signed x Title: Date: FOR-DEPARTMENT USE ONLY _ Application Accepted by Area _ ❑ Stk 466-6781 Additional Comments: `r ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by -Date "i ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY t t DATE- PERMIT NO. I INFO _ *- EH 13-24 REV. 10/82 10/82 500 14-26 10