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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p � � Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED �T (Complete in Triplicate) ��' Application is fietehY made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinse�., Tappcat 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. /(fpr. Q e-1) A�U4 City Lot Size PM Job Address f `� , .`ieAddress Phone Owner's Name f rl Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ PROP. LINT DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. 'i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11 Open Botto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Fz k ❑ Tracy Type of Casing Specifications P Public 1-7 Other ❑ Delta Depth of Grout Seal Type of Grout I[ I i Irrigation —,Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 5101 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADD1T10N I I DESTRUCTION (No septic system permitted if public sewer is 'available within 200 feet.i 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 ❑ Type/Mfg Capacity No. Compartments II PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Pouhdation- Property Line SEEPAGE PITS l I Depth Size Number j SUMPS Cl 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 shalt 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 ff certifies the following: "I certify 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." { The applicant must call for all require inspections. Complete drawing on reverse side. Signed X Title: Date: 2MEPARTIMEINIT USE ONLY _. _. �• 1 Application Accepted by Date Area Pit or Grout Inspection by1 Date fl FiFinal Inspection by Date r Additional Comments: v ��0 ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE OUNT REMITTED CASD RECEIVED BY DATE PERtNIT tv0. INFO I + EH 13-241REV.1�n51s ZZ � EH 14-26 ..r