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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT e 1601 E. HAZEL T ON AVE., STOCKTON, CA `� Telephone (209) 466-6781 '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 the Rules and Regulations of the San Joaquin Local health District. Job Address Ci Lot Size PM' Owner's !Name Address Phone Contractor..-_� t- Address 6 g-. � `�L License L&T Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE NS 6 ,� ❑ Industrial ❑ Open Bottom O-Manteca-Dia:of-Well- Ion T Dia. of Well Casing �J ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy V o Casing Specifications f`l Public ❑ Other El Delta "-�6x Depth of Grout Seal " Type of Grout I I Irrigation Approx. Depth astern Sii09 •Seal Installed by- Repair y Repair Work Done ❑ Type o H.P. 1 State Work Dgne _ Welt Destruction ell Diameter Sealing Material (top 501 j Depth Filler Material-(Below 50'-) TYPE OF SEPTIC WORK: INEW INSTALLATION I7 REPAIR/ADDITION {-I DESTRUCTION (No septic system permitted if public sewer is 1j i. s available within 200.feet.) Installation will serve:`: Residence Commercial_. Other Number of living units Number of bedrooms r" Character of soil to a depth of 3 feet: 5 .v a Water table depth SEPTIC TANK ❑ Type/Mfg 4 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 t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth �1 Size Number i _ e SUMPS Cl Distance to nearest: Well Foundation '^Property Line f 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 t 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." '<E The applicant ust call for all required in ctions. Corrfplafe'drawing,on reverse si 5 f Sign Title: Date: R D fiT LY ; Application Accepted by Date Area Pit or Grout Inspectionby Date Final Inspection by Date A tro Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma#fteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O.' Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r.EH 13.24(REV.I EH 14-28 . I