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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 R j, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. s.2 x. (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. I Job Address City Lot Size ` v l' pM Owner's Name AddressLphone { Contractor Address n } License No. Phone WELL/PUMP: NaWELL ❑ WELL REPI ACFMFf4T ❑ DESTRUCTION ❑ I PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.. 0 NEAREST: C TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDAT AGRICULTURE WELL OTHER WELL PlTS/SUMPS INTENDED USE,. TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS ❑ Industrial », > `'^.,� ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private' CJ Gravel Pack El Tracy Type of a Specifications ❑ Public +❑ Other 'Cl Delta Depth of Grout Seal T ype of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done l` Well Destruction ❑ Well Diameter Sealing Material (top 50') Ip! Depth �- Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION fPT REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sstem permitted if public sewer is .1 N available within 200 feet.) E- Installation will seine: Residence_ Commercial_ Other I� Number of living units: Number of bedro s -� Character of soil to a depth of 3 feet: Water table'depth— �� SEPTIC TANK ❑ Type/Mfg Capacity vNo. Compartments PKG. TREATMENT PLT. ❑� �,,+� Method of Disposal } Distance to nearest: ' Well Foundation. Property Line-74 I LEACHING LINE ❑ No. & Length of lines -11 Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation _Property Line j SEEPAGE PITS Number ' SUMPS ❑ Distance to nearest: Wel Foundation - Property Line DISPOSAL PONDS ❑ .:i I 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 l 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 l 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 shelf employ persons subject to workman's compensa- tion laws of California." F { } The applicant must call for all ir-Ouirec inspections. Co p ate drawing on side. , Signed Title: Date: I� FOR DEPARTMENT SE ONLY � !� Application Accepted by Date �� Area 02— Or Grout Inspection by Date -7�S - Final Inspection by Date– f�,�7_C. Additional Comments: a�, ❑ Stk 466-6781 ❑ Lodi; 359-3621 ❑ Manteca 823-7104 - ❑ Tracy 8335-638,5 i Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE CK it INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t + EH 1 -241REV.t/as) EH 1428