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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 Address t�C 9�t%� "~' � City of Size PM Owner's Name 1Z�I Address �/*�� 14 Phone Contractor �� AddressM YG a4t,r 6 7: License [V0.� �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE ONE ANK SEI/UER LINES DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WELL OTHER WELL — INTENDED USE TYPE OF WELL PROBLEM AREA CON NSP NS © Industrial El Open Bottom ❑ Manteca D' a Excavatio �Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tr Type of Casing pecifications M Public ❑ Other (1 Delta Depth of Grout Seal f�Grout _ 11 Irrigation _ prox. Depth 11 Eastern Surface Seal Installed by �} Repair Work Hone Type of Pump H.P. State Work Done Well De on ❑ Wel! Diameter Sealing Material Itop 5d') Depth Filler Material (Below 501- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (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. ❑ isposal Distance to nearest: Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total en FILTER BED ❑ Distance to near Well Foundation Property Line i SEEPAGE PITS epth Size Number I SUMPS ❑ Distance to neatest: Wel! Foundation Property Line DIS ONDS ❑ 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 1 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 Calif The applican II f r quired&ction omplete dr ing on rev side. Signed Title: c/� f Date: FOR DEPARTMENT.USE ONLY Application Accepted by – DateArea © ^,,, 7 Pit or Grout Inspection by 3 Date .F Final Inspection by 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 INFO AMOUNT DUE AMOUNT REMITTED CSD RECEIVED BY �DTATE PERMINO. + EH 13-24 IREV.1/"5) 15 [ EH 14-26 CC..JJ ..l