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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 1'YEAR FROM DATE ISSUED 1. (Complete.in Triplicate) Application is heieb made to the San Joaquin Local Health District for permit to construct and/or install the work herein described. This application is App. y q 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 i Local health District. ; �D i of Size PM Job Address , � + f Phone Owner's Name icense Nc, hone ° Contractor TYPE OF WELL/PUMP: NEW EL WELL REPLACEMENT El - DESTR TION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ y OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Type f l-1 Public nOther f�Delta. _ -• -Depth of Grout Seal- - T YP of Grout I I Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P, State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501. Depth Filler Material (Below 501 — C, TYPE OF SEPTIC WORK: NEW INSTALLATION f -•REPAIR/ADDITION iJ-DESTRUCT.ION LI.(No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: ResHence T-1 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -ti Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal t Distance to nearest: Well,C._ Foundation d Property Line J^� 1 ' �� Total length/size LEACHING LINE ❑ No. & Length of lines �//�g� l�0 FILTER BED ❑ Distance to nearest: Well fes— Foundation Property Line i SEEPAGE PITS I 1 Dep11i=`= �c- Number LI Distance�,o nearest. We �;, � .r--Eoundation- t � j- _ Property Line DISPOSAL PONDS ❑ 1 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 Diktrict. 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 lawsof California." The applicant al squire in c ions. Com ate awing on reverse side. Signed X Title: Date: • FOR DEPART ENT USE ONLY / Application Accepted by Date r < Area l I Pit or Grout Inspection by Date Final Inspection by� Date r Additional Comments: - — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 04 ❑ Tracy 835.6385 k 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 CACKSH RECEIVED BY _DATE PERMIT'NO.' � INFO s/16 Cl C� i ♦ EH t3-241REV.1/951 EH 14-26 F