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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 NO PERMIT EXPIRES TYEAR FROM DATE ISSUED No (Complete in Triplicate) iApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein scribed. T 's appEicauan 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 I Local Health District. } Job Address City Lot Size PM Owner's Name y �/� 4 Address Phone/ zv— / Contracto fr Address Li cense N Phon TYPE OF WELL/PUMP: _ NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION Eli - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT DISTANCE TO NEAREST: SEPTIC TANK_ _ SEWER LINES _ FLD. PROP. LINE FOUNDATION A G#iICULT��-URE WE OTHE R yy/ T PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications I'1 Public ❑ Oth 9 9 Delta Depth of Grout Seal i I Irrigation Type of Grout g" --Approx. Depth I I Eastern -- Surface Seal Installed by >Destr k Don Type of Pump * H.P. 3 State Work Done_ on ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTIOI (No septic system permitted if public sewer is r available within 200 feet.) } Iristallation will serve: Residence Commercials Other Number of living units: Number of bedrooms n z 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 v LEACHING LINE ❑ No. & Length of lines ~` - ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ! I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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 applica ust call for all,required inspections. Complete drawing on r rse side. Signed Title: Oate: J .' - FOR PARTMENT USE dN �� LY Application Accepted by Date l` " �., Area Pit or Grout Inspection by _ .. 1; Date Final Inspection by ate r Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 EJ Manteca 523-7104 ❑ Tracy 635-6385 J Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE MOUNT REMITTED INFO AMOUNT DUE ACK -RECEIVED BY DATE PERMIT`NO. r EH 13-24(REV.1/115) �� - - EH 14-2e