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APPLICATION FOR PERMIT -0.- SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) i 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. p Job Address' `4 �d � City iA Lot Size PM Owner's Name In Address 6 Phone Contractor Address / License No. Phone'YG�f`��6� TYPE OF WELLIPUMPr NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ( ❑ Delta Depth of Grout Seal Type of Grout �. I I irrigation _..Approxi Depth I ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 t Depth Filler Material f Below 501 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 i Number of living units: Nurriber of bedrooms Character of soil to a depth of 3 feet Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance10 nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth I 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, and rules and regulations of the San Joaquin Local Health Diltrict. 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 applica must Gail for all r quired inspe tions. Complete drawing on reverse side. Signed Title: Date: + FOR DEPARTMENT USE ONLY Application Accepted by 1A1 Date q~ Area Pit or Grout Inspection by Date Final Inspection by Date p 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 95201FEE ! INFO AM(OU�NT DUE r AMOUNT REMITTED ASH RECEIVED BY DATE /gypPERMIT NO. +.EH 13-24(REV.r/N5f EH 14-29 I i