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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I (Complete in Triplicate) Application is he+eby 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. i I Job Address - City Lot Size PM Owner's Name Address L� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 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 pia. of Well Excavation Dia. of Well Casing D Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ III Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Materiai (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION i 1 DESTRUCTION14 INo septic system permitted if public sewer is available within 200 feet.) =� Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal _.� 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 I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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 taws 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 app- u call all re d inspection Complete drawing on reverse side. Signed X Title: __ Date: FOR DEPARTMENT USE ONLY �7 Application Accepted by DatArea q /Pit or Grout Inspection by �. Ine Final Inspection b � A { � Date Additional Comments a (_I -_�5 ❑ Stk 466-6781 ❑ Lodi *-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMn'NO. .-EH 1 -241REV.1i85Y < EH 144-28 a 1