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VCAPPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon iscation is made nticompliance with SanoJoaqu nthe SanCounty Ordinance Joaquin lNo.District Health 49 for sewage or INo . 1862 for ell//pump and the Rules and R gulations of he San t to construct and/or install the work herein describ .THs l Joaquin Local Health District. CityLot Size AL PM Job Address l ' 1 l `Q� Address `f Phone 7�7'S�a?1 Owner's Name ,47 Contractor's Name t�– License No. 30 S7.2Phone 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 WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications El Public El Other L1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ sepeticwitsystem 200 feet.)permitted if public sewer is Installation will serve: Residence — Commercial— Other Number of living units: t Number o bedrooms A p Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg .(� apacity_. A5 - No. Compartments Method of Disposal 1– PKG. TREATMENT PLT. ❑ 1 �a! Distance to nearest: Well Foundation ' Property Line�— Total length/size LEACHING LINE C�No. & Length of line 14f4 Property r t FILTER BED ❑ Distance to nearest: Well !r Foundation_14 �—. Property Line SEEPAGE PITS ❑ Depth Size F Number SUMPS M 'Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS Ll 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 applicant must call fo all required inspections. Complete drawing on reverse side. Signed Title: © �� Date: 1 J FOR DEPARTMENT USE ONLY A Application Accepted by Date ! . Z Area J [� t Inspection b Date _ Final Inspection by Date Pit or Grou pe Y l f t Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-36'11 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 y FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. � INFO �rSlo.` a +EH 1324(REV.10183) EH 1426