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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) EJob is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is mpliance with San-Joaquin County Orainance'No.-5`9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin h District. 1 s r �• City f Lot Size- PM me `' – Phone r AddressLicense No. Phone ELL/PUMP: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAC_FLD. PROP. LINE FOUNDATION AGRIC URE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS r i1 ❑ Industrial ❑ Open Bottom ❑ Manteca ia. Well Excavation Dia. of Well Casing kvl�y� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of ing Specifications ('I Public ❑ Other i 1 Delta Depth of Gro Seal Type of Grout I I Irrigation _--Approx. Depth I I Eastern Surface Seal Inst ed iby Repair Work Done ❑ Type of Pump P. t Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION i I DESTRUCTION INo 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 sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line 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 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 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 an n in suc nor ais to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies a following:UI certify at in the pert mance of the work for which this permit is issued, I shall employ persons subject to workman's compansa tion la s of California." he a plicant mLA call for all r fired " nm drawing on feverse side.Signed ' 'Title: 1 Date: FOR DEPARTMENT USE ONLY /0 Application Accepted by Date r Area / Pit or Grout Inspe r y Final Ins action by[ t w ,l.[�, Date Additional Comments: Errnt 2 Z� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. INFOrest G G + EH 13-241REV.1/85) EH 14-M