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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address d �' City elX4. Lot Size PM Owner's Name Address f Contract _Addres :S et License Pho JS 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 PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC ❑ Industrial EJ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications FI Public =1 Other elta Depth of-Grout Seal - Type of Grout i 1 Irrigation ____�Ap epth I I Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H.P. State Work Done _ Well Destructio Well Diameter Sealing Material (top 50'1 C Depth Filler Material (Below 501 C TY E OF SEPTIC_ WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is 1 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: VVA ha¢le depth SEPTIC TANK ❑ Type/Mfg Capacity fnpartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines T Total length/size • FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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."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." The applicant t II for all iequired i tions. Complete drawing on rev rsl9 side. Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by S( •--t� Date 4Z. Area p 1 Pit or Grout Inspection by Date Final Inspection by-,-P. Date 41a4 p Additional Comments: 7 l 7 a—� f z S ❑ Stk 466-6781 ❑ Lodi 369-3621 L] 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 INFO AMOUNT DUE AMOUNT REMITTED C 8H RECEIVED BY DATE PERM]IT(��N�Of. r EH 1324(REV.I/K5) -2� C r-Sf