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-- APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA W T616phone (209) 466-6781 �? I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C� ;: ' • . (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 we Local Health Districtll/pump and the Rules and Regulations of the San Joaquin " ,;Si,. Job Address f i City DC d Lot Size �� PM Owner's Name " ! /4,m gadress ' ,I - / Phone b Contractor Address ` License No, � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJPhane PUMP INSTALLATION DESTRUCTION LJ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑�� SEWER LINES DISPOSAL FLp. LftVP INE FOUNDATION AGRICULTURE WELL OTHE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS --------------- PETS/SUMPS 3 ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ED Domestic/Private LI Gravel Pack ❑ 7ra ❑ Public Type of Casing Specifications ❑ Other Deltas Depth of'Grout Seal E3 Irrigation _�gppro epth El Eastern Type of Grout Repair Work Done ❑ Ty Pump 1 H P Surface Seal Installed by IF Well Destruction . i� i State Work Done_ ell Diameter � Sealing Material (top 50 ——Depth -.Filler Material-{Below-50')-^ - -- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAfR!ADDlTION ❑ DESTRUCTION (No septic system W permitted if public sewer is Installation will serve: Residence_ Commercial, Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r SEPTIC TANK - ❑ Type/MfWater table depth g PKG. TREATMENT PLT. ❑ - Capacity_ No. Compartments 1 Method of Disposal .1 Distance to nearest: WellFoundation f Property Line r LEACHING LINE ❑ No. & Length of lines r :r .FILTER BED # _ Total lengthlsize ! ❑}. Distance to nearest: Well Foundation f t Property Line ` SEEPAGE PITS ❑.E.Depth Size , S Number SUMP ❑- Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 1 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_Dislrict 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 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." The applicant s !I or all re fired inspections. Complete drawing on reverse side, r S' ned X Title: Date: FOR DEPARTMENT�USEONLy Application Accepted by , } / Date � Area Pit or Grout Inspection by _ Date Final inspection by Date Additional Comments: -I ❑ Stk 466-6781 �LOJL(odi - 369-3s21 ❑ Mante -7104 ❑ Tracy 835&385 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 K RECEIVED BY DATE. PERMIT NO. + EH 1324{REV.t i x 51 j-I.-U EH 1428 ] 3 - � t, ' f