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APPLICATION FOR PERMIT >L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _�`� in rQ K\'k -e— City. ``" r' — f Lot Size PM Owner's Name � � Address ,0 Contractor ~ � Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WE MPS INTENDED USE TYPE OF WELL PROBLEM AREA SON StiRkJCTf SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications — f'l Public f� Ot r F1 Delta Depth of Grout Seal Type of Grout—.— I I Irrigation _.'Approx. Depth I ) Eastern y Surface Seal Installed by" d Repair Work e ❑ Type of Pump H.P.- State Work Done Well struction ❑ Well Diameter Sealing Material (top.50') Depth r Fille Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION i l DESTRUCTIO (No septic system permitted it public sewer is available within 200 feet.) Installation wilt 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 0 No. & Length of lines Total length/size FILTER BED ❑ .r.Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well foundation Property Line m 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. L Home owner or licensed agent's signature certifies the following--: 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 taws 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." Th ant ust call for all r in ons. Complete drawing on reverse side. igned Title: _ Date: �d FOR DEPARTMENT USE ONLY Application Accepted by Date Area f Pit or Grout Inspection Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ mankob 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 RECEIVED BY DATE PERMIT'NO. INFO C , ♦ EH 13-24(REV.V/H51 `_y (�U 3S Fs- - EH 14-2e _�J,� t. "