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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 1 YEAR FROM DATE ISSUED . j .. (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. a { City Lot Size Job Address Phone Owner's Nam '�` Address # Phon ^ Contractor_� � Address License No ,t,_, . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC,TA1NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OFIWELL P90BLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public n Other r Fl Delta Depth of Grout Seal Type of Grout--- I I routI"1 Irrigation __Approx. Depth l l Eastern Surface Seal Installed by - \ k r H.P, State Work Done _ Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 1 - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW lNSTALLATIO REPAIRlADDITION I I DESTRUCTION I I (No eptic s tam per ed if public sewer is avai ble n 200 f Installation will serve: Residenc4k Commercia=X- Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water to depth I` SEPTIC TANK ❑ _Type/Mfg Capa if N&Compartments l PKG. TREATMENT PLT. ❑ Ilihod of Dispos�l Distance to nearest: Well -Fo ndat' Pro Line f�d ,I t k y - Tot ertigth/size LEACHING LINE � Na. & Length of lines -FILTER BED . ❑ Distance to nearest: Well n a on © Property Line ISEEPAGE PITS f I Depth'+ -Size Number SUMPS L� Distance to nearest: Well Faundati P 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 iK the performance of the work for which th'is.permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." + �' I The applicant must I for II requir inspect' s. C mplete drawing on reverse side. la Signed X Title: _ Date: ( �r FOR DEPARTMENT USE ONLY ' 3 Application Accepted by _ T Date Area w i Pit or Grout Inspection Dates Final Inspection by Date by Additional Comments: t + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy '835-6385, i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT D AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. NFO CASH � Q 00 +.EH 13-24 cREV.1-W,sr EH 14-26