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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) T� Application is hereby made to the San 3oaquin 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 Aealth District.-' [JobAddress ity Lot Size M er's Name -I Address -2 Phone — d tractor Address License No. Phone E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ 'SYSTEM REPAIR LI OTHER ❑ -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGR( E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELLBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open e ❑ Manteca Dia. of Well Excavation Oia. of Well Casing c ❑ Domestic/Private ravel Pack _❑ Tracy Type of Casing Specifications F Public 1-1Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout _I 1 11 r —.-Approx. Depth I I Eastern Surface Seal Installed by _ air Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION IJ DESTRUCTIO o septic system permitted if public sewer is F -_ — - --_ - — - f - available within 200 feet.) Installation will serve: Residence Commercial_ Other I�} r Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ,L1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property.Line fav LEACHING LINE ❑ No. & Length of litres Total length/size FILTER BED ❑ Distance:to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distancetonearest: 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 Sart 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 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." i The applicant mut call for all req 'ed ins cti s. Complete drawing on reverse side. .�igned Title. _ Date: e FOR DEPARTMENT USE ONLY Application Accepted by �fv `� �7f Area 1 V Pit or Grout Inspection by } Date incl Inspection by Date Additional Comments: + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 1335-&385 10, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 ,j- - FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. � G *.EH 13-241REV_t7--5) �� J aD oO�;L- • EH 1426