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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 (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 10 City Loi Size PM Owner's Name ff ddress Phone Contractor x`144l ✓�!_Address fP �jq License No.2 r �� PhoneZ �7 $ � 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 OTHE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private �] Gravel Pack ❑ Trac Type of Casing Specifications F1 l Public f� Other elta Depth of Grout Seal Type of Grout _ i I Irrigation �.-Appro pt I I Eastern Surface Seal Installed by Repair Work Done ❑ T o Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION{ i DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i;VType/Mfg Capacity No. Compartments CIL PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 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 follow' "I Cy t tion laws of Cali rni hat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- ' The applicant m t c I r all equired inspections. Complete drawing on reverse side. �y Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date_ �� i- $� Area r Pit or Grout Inspection Date Final Inspection by Date A — r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y INFO CASH DATE Y PERM17'N0. + EH i3-241REV. EH 11-2e