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APPLICATION FOR PERMIT ) SAN JOAQWN 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) 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. Job Address __ �' t� City Lot Size _�.- S PM Owner's Name Address13 a Q Phone J"— Contractor Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ER LINES OSAL FLD. PROP. LINE FOUNDATION AGRIC TURF WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS CJ Industrial ❑ Open Bottom ❑ Manteca ia. f Well Excavation Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack EI Tracy Type of sing `Specifications f'l Public FI Other Cul Delta Depth of Gr t Seal Type of Grout I I Irrigation --Approx. Depth I I tern Surface Seal Ins led by �+ Repair Work Done ❑ Type of Pump H.P. ` State.Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION i I DESTRUCTION" I (No septic system permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence_' Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal : Distance to nearest: Well Foundation Property Line Ir LEACHING LINE D No. & Length of lines Total length/size M FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS f 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ I hereby certify that 1 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. i 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 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 ust call or I require inspections. Complete drawing on reverse side. (1� Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by � Date b�c Area ! Pit or Grout Inspection by Date inal Inspec ion by Date ( J Additional Comments: '�L/ e 1/ _� r ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE rrr INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.1/n 5sLJL.J EH 14-28