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t: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T Ofd AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3 City Lot Size PM Owner's Name Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cil PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD<fi LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Trac fi Y Type of Casing Specifications — M Public C1 Other F Delta Depth of Grout Seat Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Instalied 6y Repair Work Done ❑ 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 INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serine: Residence_ Commercial_ Other INr Number of living units: Number of bedrooms Jr Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ID Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - ,;� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines _ r Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Proper�ypLpne ..2 w. „r SEEPAGE PITS l I Depth Size's Number r SUMPS Ll Distance to nearest: Well A. Foundation Property'Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared this applicafigriland that t e work will be done in accordance with San Joaquin county or rules and regulations of the San Joaquin Local Health District. dinances, state laws, and Home owner or licensed agent's signature rtifies the following: "I certify that in the employ an pe ormance of the work for which this permit is issued, I shall not p y y person in such manner as to b come subject to workman's compensation la s of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: S 4Date: FOR DEPARTMEIVT USE ONLY c Application Accepted by Date ` �9 • � Area }� Pit or Grout InspectionDate Final'lnspection by / Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 9501 + FEE AMOUNT DUE AMOUNT REMITTED INFO �y I( RECEIVED 8YEO? PERMiT"NO. t EH 14-24)REV.!/ s1 7+161 �o �r - EH 14-28 ��lll ✓