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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 L� 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 CouW Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,ham Job Address L5 1� 3 City Lot Size 57a ' PM c Owner's Name Address Phone Contractor Address - License No. - Phone TYPE OF WELL/PNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE WELL PROBLEM ARE STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications FI Public r 1 O 171 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work D ❑ Type of Pump H.P. State Work Done Well pest tion ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTIONPqft septic system permitted if public sewer is ilable 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size Number SUMPS ❑ Distance to nearest: Well . 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."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 st II for ail required i ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted Date rea Pit or Grou spection by Date Final Inspection by Date Additional nts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO M�OUNTT'DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. + EH 13-21[REV.