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APPLICATION FOR PERMIT SAN JOAQGiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 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 tie Rules and Regulations of th an J aquinn Local Heal (�Ac� Job Address Z ,/ f/� b ivision Name Owner's Name r ! Address` Phone Contractor's Name ce he No. e �/� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK J 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 ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ��(Public LL ❑Other ❑Delta Type of Casing I i Irrigation Approx. []Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout. �� ❑Other Surface Seal Installed by Repair Work DoneTy pe of PumpState Work Done. S Well Destruction — Well Diameter Sealing Material (top 50') U Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size (/ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number C SUMPS ❑ Distance to nearest: Well Foundation Property Line p DISPOSAL PONDS ❑ R 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 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 compensation laws of California." The applic.Int must cal•1 for it required inspections. Complete dra on rev se sip e. . Signed Title: Date: / FOR 'PARTMENT USE Y Z �/Stk 466-678 Application Accepte by(��/ Area Additional Comment : / (/1"2 ❑ Lodi 369-3621 Pit or Grout Ins ection b Date ❑ Manteca 823-7104 Final Inspection by Date �-�--`d- �i ,� ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 10/82 500 EH 13-24 REV. 10/82 14-26