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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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. I Job Address ` Cites of Size PM .00, Owner's Name Address O Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER V a,, C - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public L1 Other � �. Cl Delta Depth of Grout Seal Type of Grout I I Ifrigalion —.-Approx. Depth I 1 Eastern Surface Seal Installed by _ O Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 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 I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1l1 Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines r Total'length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll 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 t 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 Ca'ornia." The ap ' ant m t call for a re uir spections. Ca�nplete drawing on reverse side. Signed Title: -ADate: FOR DEPARTMENT USE ONLY Application Accepted by � CP1lf, Date Area l Pit or Grout Inspection byys/ Date Final Inspection by Data�34 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 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 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH 1 �? + EH 13-24(REV.)/145f U �Q �(� 30 EH 14.26 [UU1 VVV !!!