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�•T 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 Local Health District. t Job s'� `' Addres7 �Ay City Lot Size PM Owner's Name ��.� t-�i A ,� �� - 'Phone n Contractor ddress " � 41�Lcense No/7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE j FOUNDATION� AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL j PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial { ❑ Open Bottom ❑ Mantec Dia. of Well Excavation T Dia. of Well Casing ' ❑ Domestic/Private - ❑ Gravel Pack ❑ T y Type of Casing Specifications I`1 Public ,., n Other Delta Depth of Grout Seal I Type of Grout _ a. I I Irrigation _Approx. D I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material (Below 501 4 ..TYPE OF SEPTIC WORK: NEW INSTALLATION (:1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is r e available within 200 feet.) I Installation will serve: Residence Commercial_ Other + i Number of living units: Number of bedrooms j - Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK ❑ Type/Mfg W = 'Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ - _ Method of Disposal 'a Distance to nearest: Well Foundation Property.Line r LEACHING LINE .❑ No. & Length of lines s Total length/size r FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE (?ITS I I Depth Size 1 Number t SUMPS Cl Distance to nearest: Well Foundation Property Line ! DISPOSAL PONDS ❑ f 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. Hone 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 person's subiect to workman's compensa- tion,laws of California." The applicant m t c for requ" i e pections. Complat wing RZ side. a i Signed X Title: Date: 1 FOR DEPARTMENT USE ONLY t Application Accepted by (12 E. �u j Date Area Pit or Grout Inspection by Date Final inspection by _ Date � j, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑'Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 t k FEE r INFO AMOUNT DUE AMOUNT REMITTED 'CA8H RECEIVED BY DATE PERMIT N0. l ' +.EH13-241REV.r/n5f �—/� ,� EH 14-2e CC[..��.../// Q o a