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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 5209) 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. „ Job Address City Lot Size PM Owner's Name Address Phone V i .- Contractorddres License No. TYPE OF WELL/PUMP: AEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK'L, SEWER-LINES - DISPOSAL FLD. - - -. PROP.:LINE FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS _ 1NTE USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ I stria) ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack [ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of`Grout Seal Type of Grout i I Irrigation __Approx, Depth l I Eastern / urface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.1 State Work Don r`� Well Destruction 1-1WellDiameter Sealing Material (top 50') W Depth Filler Material (Below 50') 7 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION t.I DESTRUCTION I I (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ; Distance to nearest: Well Foundation Property Line Crn LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS. D 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 shalt 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 applicant MVst call for all r ired inspections. Complete drawing on reverse side. l Signed X Title: �_ Date: r O.FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by A d &&u Data Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621'' ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health'Permit7Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/N5) EH 14-25a`.'