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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. City Lot Size PM Job Address _ �. Address �1 1 '� Phone G -Owner's Name Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD rJPIT P LINES DATION AGRICULTURE WELL WEL I - i INTENDED USE TYPE OF WELL PROBLEM A NSTRU DNS ❑ Industrial EJ Open Bottom. nteca Dia. of Well Excavation _ Dia. of Well Casing Specifications p , ❑ Domestic/Private ❑ Gravel P El Tracy Type of Casing- Delta _ +V ' i 1 Public I� er 1 Depth of Grout Seal Type of Grout-.--. - I I Irrigation _. pprox Depth I I Eastern Surface Seal Installed by - W Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction Cl Well Diameter Seating Material Itop 501 Depth - Filler Material 1Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I i DESTRUCTIO INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth o1 3 feet: Water table depth Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. 0 Method of Disposal e' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑: No. & Length of lines Total length/size FILTER BED ❑: Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I' Depth, Size Number 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 Di§trict. 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,l shall employ persons subject to workman's compensa- tion laws of California." I The applicant must ca for all required ins ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY !� f Date `� �[ �U Area U Application Accepted by - _ Pit or Grout Inspecti Date Final Inspection by Date t 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24(REV.5/H5) ��- EH 14-2a