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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 TYEAR FROM DATE ISSUED 111 (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. Job Address o4 )ty Lot Size PM Owner's Na Address Contractor Addresas?(oym/�icense4jv?f�Phon 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/ :----- -- — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC S El Industrial El Open Bottom E] Manteca Dia. of W avation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy ype of Casing Specifications FI Public ❑ Other Depth of Grout Seal Type of Grout _. I I Irrigation _.Appro t I Eastern Surface Seal Installed by Repair Work Done ❑ of Pump H.P. State Work Done_ Well Destruct' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') RPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (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. ❑ Method of Disposal 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 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 any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." The ap ca t must call for all req •ed i spec'ons. Com lete drawing on rse side. P g S Title: Date: Date: 5-.1— FOR DEPARTMENT USE ONLY Application Accepted by Date �-� Area Pit or Grout Inspection Date Final Inspection by j�a �Date Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca E(23-7-104 ❑ Tracy 835-6385 5 / p AA3Go' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F(�d IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. O CASH M ti EH 13-24IREV.i/H5) EH 14-28