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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) 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 City 11�4t Size PM Owner's Name Phone Contractor ass [{ �/ Li4&y4lcense No. Phone t/ TYPE OF WELL/PUMP: NEWNLE01 WELL REPLACEMENT ❑ DESTRUCTION ❑ AFPUMP INSTALLSYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE REA CONST CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications M Public 1� Other ❑ Delta D h of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I East Surfa Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW l TALLATION i 1 REPAIR/ADDITION I I DESTRUCTION Y7 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 i 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 7a7 fo al quirDdrsctions. Com to wing on reverse side. Signed- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �l � U � Area ��! Pit or Grout Inspection by Date Final Inspection by�� Date Additional Comments: ❑ Stk 466-6781 ❑todi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 1 '24)REV.1/H 51 EH 144-28