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s A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA --, i ,r1.Y i Telephone (209) 466-6781 Pi,,,.v►�ppl7i.vi' i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) UtL; f 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.dof:the�$anJAoaqu�n Local Health District. �` PERMfl /SERVICES J CG Lot Size PM Job Address v City Owner's Name Address Phone � � Phone_ Contractor Address '-� License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER-❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCYTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom :❑ Manteca Dia. of Well.Excavation Dia. of Well Casing ' . Domestic/Private Gl Gravel Pack E] Tracy Type of Casing Specifications Type 1'1 Public - f} Other [_l Delta DeTpth f Grout Seal YP of Grout — I I Irrigation _..Approx. Oe h stefn Su¢ a Seal Installed by I ` Repair Work Done Type of Pump I EaH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth I Filler Material (Below 50) r TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION i-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. ❑ _ i� Method of Disposal Distance to nearest: Weil- Foundation Property.Line k! � 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 ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ cation and that the work will be done in accordance with( I hereby certify that 1 have prepared this application 'San,J6agriin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work 4.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 shali�employ persons subject to workman's compensa- tion laws of California." ' The applic st call for all req ins tions. C plate drawing on re ver ide.Fr 0 f ' Signed X Title: ,r t _ Da te: r FOR DEPARTMENT USE ONLY Application Accepted by Data Area t Pit or Grout_Inspection bys,, Date. - -- -Final Ins-ection b i- Date " Additional Comments: - ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca .823=7104 It.\g 4❑ 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 REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 1 +.EH 13-24(REV.1/h 5) ��t EH 14-28