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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT — - 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 C� � 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. dd �f7A71tv A City Lot Size PM Job A ress AMOUNT DUE AMOUNT REMITTED CK f Arc -164 WA V Phone Owner's Name Addre ss A y A _ ✓ V Contractor a Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION ❑ MZYZIAI, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T''t 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 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _-.Approx. Depth I l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 wove -j" Depth Filler Material (Below 501 TYPE OF SE IC WORK: NEW INSTALLATION I l REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number f 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: We Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _Number SUMPS Ll Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ �J r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou y 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 ? V employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature r> 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 ap n must call for all req iced i spections Complete drawing on reverse side. Signed Title: ! Date: /14 �q FOR DEPARTMENT USE ONLY Application Accepted by Date Area ` Pit pr quDh pec ion by C_�1i Date - '^b I Final Inspection by Date 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 +. EH 13.24 (REV. 1/ n 5) EH 14-2a FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. _ ✓ V