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F APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 (f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICOmplete 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 .5;2 Cit Lot Size PM Owner's Name AddressPhone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PU TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATIONLTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CO TION SPEGIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excav Dia. of Well Casing ❑ Domestic/Private ❑ Gravel ❑ Tracy Type of Casing Specifications (�y� n Public er C1 Delta Depth of Grout Seal of Grout I I Irrigation ✓ ..Approx. Depth i I Eastern Surface Seal Installed by Repair Wofk'Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 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 Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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: "t 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 mu al oral equired ins tions. Complete drawing on averse side. y[� Signed X Title: Date.If o FOR DEPARTMENT USE ONLY t5 Application Accepted by Date41 /z�7_,Area O Pit or Grout Inspection by Date Final Inspection by ate s /, Additional Comment ? °,' � f3 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. t EH 13-24(REV.1/r15) EH 14-2a C�