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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaq in Local Health District for a permit to construct and/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 far weli/pump and the Rules and Regulations of the San Joaquin Local Health District. 421! � r r � Job Address — A �� _J City Lot Size A PM Owner's Name Address Phone Contractor Address License No. Phone Ag 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 (lyy 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 Ll of Casing Domestic/Private ❑ Gravel Pack ❑ Tracy 9 Specifications fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 I 1 Irrigation __-Approx.Depth 1 1 Eastern Surface Seal Installed by foul Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material lBelow 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I 1 DESTRUCTION I lNo septic system permitted it public sewer is available within 200 feet.] Installation will serve! Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of F soil to a depth of 3 feet:';� SEPTIC TANK ❑ Type/Mfg'I Capacity No. Compartments PKG. TREATMENT PLT. El of Disposal Distance'f d nearest: Well Foundation Property Line . I rTotal length/size LEACHING LINE ❑ No. & Length of lines FILTER BED t ❑ Distance to nearest: Well Foundation Property Line 1 i SEEPAGE PITS + l I Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 1 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 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." i The applicant must call for all required inspections. Complete drawing on reverse s'do. Com" Signed X ' Title: til Data: —�� • ( FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Area r Pit or Grout Inspection by Date Final Inspection by Date S~ I I Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3. 1 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE AMOUNT DUE J AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO J� +,EH 13-24 IREV.1/R 5) 3 �� I EH 14.26 I -