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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTn- 1601 E. HAZEL 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressCity, �3 Lot Size PM Owner's Name f Address / t J � MV Phone. w Contractor i Address License No. Phone TYPE OF WELL/PUMP:u NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST- 99PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE CULTURE WE ER WELL PITS/SUMPS _- INTENDED USE TYPE OF WELL PRO A CONSTRUCTIO TIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ia. of Well Casing ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifica f'1 Public Other it Delta Depth of Grout Seal Type of Grout _. \ 1 1 Irrigation Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter Seating Material atop 501 Depth a Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR IADDITION LI DEST•RUGTION- �lNo-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 I 1 Depth Size ' f Number SUMPS ❑ Distance to nearest: Well Koundation 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. r 11 i 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':" Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, shall employ persons subject to workman's compensa- tion laws of California." + . f The applicant.,¢rust call for all required inspec ions. Complete-drawing onn]reverse side. Signed / e.QJ Tide: �t1✓r�� /v"` `r -- — _ Date: 4. ;'FOR DEPARTMENT USE ONLY Application Accepted by Date Are Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: r ❑ 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 CK igj RECEIVED BY DATE PERMI7'NO. INFO // + EH 73-21(REV.I/H 5) �� / /QEH 11-26