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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 7 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 Addressf'l [ City �Q a Loi Size PM i Owner's Name Address Contractor's Name �` License No. e Phone TYPE OF WELL/PUMP: UNE WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP DISTANCE TO NEAREST: SEPTICTANK�INSTALLATION-U SEWER LINES�a �REPAIR DISPOSAL FLC&/O� P❑ROP. LINE�� 74 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .❑�.�Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing ]omestic/Private iy'Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I-) DeltaDepth of Grout Seal 1 , Type ol)Grout Aft kkit ElIrrigation Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Dane ,❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well. Diameter Sealing Material (top 501 Depth " Filler Material (Below 50') REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms I' Character of soil to a depth of'3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments n 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 clearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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, andI 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." The appli T214ust call far all to.qquirR inspections. C piece drawinArev 'de.Signed �f Title: - Date: O FOR DEPSE ONLY Application Accepted by Date Y, Area 4 Pit or Grout Inspection by �' Date - �, �y Final Inspection by Date Additional Comments: `I ❑ Stk 466-6701 ❑ Lodi ;j 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box.2009, Stk., CA 95201 j FEE AMOUNT DUE AMOUNT REMITTED C ENFO CASH' fEIVED BY DATE PERMIT'NO. + EN 13-24(REV. 10183) Elf 14-26