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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 L al Health District. Job Address City Lot Size PM ♦t n Owner's Name Q Address Phone Contractor_�#�� Address Lig cense Ido. Phone TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEME El DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D. PROP. LINE. FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROB EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Pia. of Well Casing \ ❑ Domestic/Private ❑ Grav c ❑ Tracy Type of Casing Specifications 1 M Public _ ther ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by _ Repair Wo Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -.Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 PtSTRUCTIO Ng0septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other — , Number of living units: Number of bedrooms Character of salt to a depth of 3 feet: Water table depth SEPTIC TANK ' T_ype/Mfg Capacity No. Compartments PKG. TREATMENT PL . ❑ Method of Disposal R Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines _2 f Total length/size r` FILTER BED ❑ Distance to nearest: Well 'eFoundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 qui Local Health Di§trict. Home owner or lice agent's signal a certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any n in such manner a o become suZtokman's compensation.laws of California." Contractor's hiring or sub-contracting signature certifies t following: 'I certify t m the performaork for which this permit is issued, I shall employ persons subject to workman's c pensa- tion lawThe applicant mu c I or all required in tions. rawing on re r side. s� �iI Signed X Title: Date: ( Y -�-�7 FOR PARTMENT USE ONLY / ApplicatLAccept�edby \�[rDate Pit or Grout Inspection by Date Finall Inspection:b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Manteca 3-7104 ❑ Tracy 83526385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CA�5H{�/ RECEIVED BY DATE P'ERMIYNO. FEE a EH 114EH 3-24-26 v