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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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. rr,: E f ' �/ 4Lot SizeZZ PM Job Address Ci" 11d Owner's Name Phone T` w �.. Contractor Address License No. Phone OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARS PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS 1 © Industrial Q Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy Type r_:Specifications ❑ Public ❑ Other ! ❑ Delta Depth-of�Groutea Type.of Grout ❑ Irrigation i _ —Approx}Depth ❑ Eastern Surface Slled by Repair Work Done ❑ Type of Pump H,P. 1 State Work Done \�. Well Destruction ❑ Well Diameter -Sealing"Material(top.50') f Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 1 REPAIR/ADDITION ❑ DESTR I N (No septic system permitted if public sewer is 7;� ' I ,�_ I dable within 200.feet.) Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms S ` Character of soil to a depth of 3 feet, !Water table depth SEPTIC TANK ❑ Type/Mfg Capacity "_jNo. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:" Well Foundation Property Line f SEEPAGE PITS ❑ Depth t Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O ". " 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 performer a 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." f - The ap "cat st call for all required inspections. Complete drawing on reverse side. r,r y� Sign Title\ FO DEPART USE ONLY Application{Accepted byDate 3— 3 —f Area-79 d Pit or Grout'inspection by Date Final Inspection by Date. " 1 Additional Comments_ h ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823 04 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 72009, Stk., CA 95201 fI INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMWNO. + EH 13.241REV.1/857 EH W.V