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n c c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 � f Job Address ° City � Lot Size PM �hA i�vnl o A A VPhone e Owners Name Contractor Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WE ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST PECIFICATIONS P n. ❑ Industrial ❑ Open Bottom ❑ Mantecaia. of Well Excavation Dia. of Well Casing Why ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �� ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair WorkD Type of Pump H.P. State Work Done 4 Wel ruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION '(No septic system permitted if public sewer is available within 200 feet.) i 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r 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 ❑ Depth Size Number SUMPS ❑ 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 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 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." .1 T. The a licant must call for II squired inspections. Com ete drawing on reverse side. Signed Title: n � cf, Date: 41 FOR DEPARTMENT USE ONLY Application Accepted by "� Date At,'— r', Area _ �f Pit or Grout Inspection by (� Date Final Inspection by Da[8– Additional Comments: by Date 7I � C G "a. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK / RECEIVED BY DATES/J PERMIITT'NO. + EH 13-241REV.1/8 6) 0C EH 14-26