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APPLICATION 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) 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. 18621 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1!1 Job Address © City Lot Size j PM Owner's Name AddresspPhone Contractor_ Address r �/ License No_ Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Othe ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done Type of Pump H.P. State Work Done Well Destr ' n ❑ Well Diameter —Sealing Material (top 50') ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lr REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is {; a available within 200 feet./ Installation will serve: Residence_ Commerciale .Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacihNo. Compartments PKG. TREATMENT PLT. ❑ Method of�Di§Pj°sal Distance to nearest: Well Foundation 0 __.- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well/t�D Foundation Property Line SEEPAGE PITS ❑ Depth X I&X4csize .61._ Number UMPS ❑ Distance to nearest: Well 16:0 Foundation�� Property Line D S! POSAL 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 r 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 bdcome subject to workman's compensation laws of California."Contractoes 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 st for alrre ' d inspections. Complete drawing on r�vexse side. �j i i /�/ C Signed Title:�, Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date f � � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13-241REV.1/95) -7o. C)t7 EH 14-26 t