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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Or Telephone (209) 466-6781 W 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 f L � City Lot Size PM Gr' Address '� Phone zr � Owner's Name _�— — Contractor �e Address ~ = License Na3�—Rhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUC ECIFICATIONS ❑ Industrial Q Open Bottom _.,,._ .❑ Manteca„_- _ ell-.E;xcavation „_.Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications I"1 Public F1 Other Delta Depth of Grout Seal Type of Grout — I I Irrigation �.-Appro epth l 1 Eastern Surface Seal Installed by - !� Repair Work Done Ll Ty ump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 50'1 e Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTIO.NkIlPiNo 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 o1 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 ye 4' i 1 LEACHING LINE ❑ No. & Length of lines ^ry ~Total,length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line ;— .j SEEPAGE PITS –�"–`–_71 ""Depth Size ' Number SUMPS `1,1 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-contraciing signature certifies the following: "I cartify 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." Theapplicant must call for all required inspections. Complete drawing on reverse s'd i Signed X Title: Date: �^ r USE ONLY Application Accepted by * F Date Area j �6/�� d Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 7,9 ❑ Stk 466-6781 ❑ Lodi 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 95201 FEE AMOUNT RUE AMOUNT REMITTED cASHK INFO cRECEIVED BY DATE PERMIT'NO. 11 + EH 13-24(REV.1 i H 5) y r}�7 -2 [ . EH 14-25