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APPLICATION FOR PERMIT ZZ SAN JOAQUIN( LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 H 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. i X lob Address /j I Cit Lot Size S da r PM Owner's'Name Addresses �� ' ) ` Phone .Contractor_- `Address TYPE OF WELL/PUMP: License No.__� _Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU...- PUMP INSTALLATION El SYSTEM REPAIR ❑ DISTANCE TO NEAR EPTIC TANK THER ❑ SEWER LINES DI AL FLD. PROP. LINE FOU N AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PITS/SUMPS _ EM AREA C RUCTION SPEC]FICATI ONS ❑ Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tr --- Dia. of Well Casing M Public Type o Specifications ❑ Other Delta Depth of Grout Se I i Irrigation �Appr epth 1 1 Eastern Type of Grout Surface Sea! Installed by V Repair Work Done ❑ of Pump H.P. — Well Destruction ❑ Well Diameter State Work Done Sealing Material (top 50') -Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTIO Wo septic system perm"Publicsew.,Installation will serve: Residence_ Commercial! Other available within 200 feetNumber of living units: Number of bedroomsCharacter of soil to a depth of 3 feet:SEPTIC TANK ❑ Type/Mfg Water table depthPKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Method of Disposa Foundation Property Line�� I LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line i t SEEPAGE PITS 11 Depth Size Number SUMPS El Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Property Line 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 Di§trict. 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 P to that in the Performance of the work for which this permit is issued, f shall em tion laws of California." employ parsons subject to workman's compensa- The applicant must tali for all requireinspections. Complete drawing on reverse side. Signed X _ 4 �� ulYl P/L Title: Ir�� Date. 1 ' FOR DEPARTMENT USE ONLY � Application Accepted by Date Area Pit or Grout Inspection by ;y —��. Final Inspection by W Additional Comments: Date Date ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823=7104 5-63 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E❑Hazel on Tracy 3Ave., P O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REM1TTEp CK y� CASH RECEIVED BY DATE PERMIT'N0. ♦.EH14-24fREV.Iix51 �� c�1 � �rr� � �9 } EH 14-2e �i Y �� O�_tl�� , I