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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE.T ON AVE., STOCKTON, CA r 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. x rt Job"Address v City Lot Size �j PM Owner's?Name �y Address Contractor f C Address 6 License N 0-1 Pho a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL ITSISUMPS INTENDED USE TYPE OF"WELL PROBLEM AREA CONSTRUCTiO !CATIONS ❑ Industrial • ❑ Open Bottom ❑ Manteca Dia- e l Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`1 Public f l Other i, .,,._.. ., ..�1 —�,. Depth af_Grout_$eal Type of Grout t I I Irrigation —..Approx. Dept I Eastern Surface Seal Installed by � Repair Work Done ❑ Type of H.P. State Work Done Well Destruction e11 Diameter Sealing Material (top 50'1 { De th ' " Filler Material (Below 50'1 Depth i TYPE OF SEPTIC WORK: NEW GNSTALLATION ("I REPAIRIADDITION l 1 DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence ?_ Commercial_ Other Number of living units: Number df bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Pr perty Line LEACHING LINE ❑ No. & Length of lines. Total length/size -No. FILTER BED w ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth. Size Number SUMPS Ll Distance to nearest; Well f=oundation Property Line DISPOSAL PONDS ❑ 4 _� F 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. Homeowner or licensed agent's signature certifies the following: "!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 l certifies the following: "I certify that iii-theperformanceof the workJor"which this.pormit is issued,I shallemploypersons subject to workman's compensa- tion laws of California." ! t The applican ust call for all required inspections. Complete drawing on revere side. Signe Title: Date: ` " ,FOR DEPARTMENT USE ONLY pp l Application Accepted by Date "' Z r a3 Area Pit or Grout Inspection by Date Final Inspection 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 2009, Stk., CA 95201 Y FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.Es 13-24 f REV.i/n 5)[7 EH 14-26