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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address "� Gity �'1 //R� Lot Size PM ozcOwner's Name Address 'd Phone 33 6 Contractor C Address -�� ' License iVo. Phone �51 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-El �-, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D1SP0 PROP. LINE FOUNDATION AGRICULTURE'WELL : HER WELL PITS/SUMPS :, INTENDED USE TYPE OF WELT. PROBLEM AREA � C0� UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom .,� ❑ Manteca• Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy 'd Type of Casing Specifications FI Public R Other ❑ Delta ,;f Depth-of Grout Seal Type of Grout ! Irrigation _ rax. Depth l I Eastern Surface-Seal Installed by - Repair Work Done ❑ ype of Pump H p < State Work Done Well Destruction ❑r Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION I I DESTRUCTIO (No 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 ❑ Type"/Mfg 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 FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS lel- Depth iSize Number r 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 San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"Vicertify that in the parformanceCof"the-work for which-"this permit-is issued, k st all 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." f Theapplicant must call for all required inspections. Complete drawing on reverse Signed Title: (�rj Date: FOR DEPARTMENT USE ONLY f Data Area Application Accepted by ` Pit or Grout Inspection by . Date Final Inspection by_ �'�� Dat 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 FEE AMOUNT DUE AMOUNT REMITTED I CK V CASH RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13-24(REV,I/H 5) EH 14-26