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k r � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA l� Telephone (209) 466-6781 kv f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —>k (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 Ordin.Nce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Ci of Size PM Owner's Name ress Phone (4T) Contractor Address License No. Phone TYPE OF ELL/PU NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION Ll _ SYSTEM REPAIR*❑��— —x.. —OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public Fl Other r'--1 Delta Depth-of Grout Seal Type of Grout I i Irrigation _-Approxi Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ T rp p Type of Pum H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION)( 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve. Residence_ Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK EDType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line SEEPAGE PITS I I Depth Size Number i F iSUMPS ❑ 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 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." Thea plican t call for all uired s ��,�a q pe omplete drawing on r rse side. (' Signed X Title: Daw +a g Date: FOR DEPARENT USE ONLY Application Accepted b Date _Area i Pit or Grout Inspection by Date Final Inspection by Date�B 62 Additional Comments: l� ❑ 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 95241 FEEINFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERMIT NO. l + EH 13-241REV.F/R51 11D EH 1428 f�