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r k APPLICATION FOR PERMIT 4 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Z � h 1,14 R ISD O �- ��' PM Job Address L City Lot Size f 62Q CI Owner's Name W ss Contractor Address- License-No.- - ---Phone. 4!`� i TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION LI i I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 3 DISTANCE TO NEAREST: SEPTIC TANK TR ,�, LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION LT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 4*CONSTRUCTION SPECIFICATIONS f ❑ Industrial n C❑ Open Bottom Dia.--of Well Excavation Dia. of Well Casing O Domestic/Private ❑'Gravel Pack Type of Casing Specifications-M Public f} Other Depth of Grout Seal Type of Grout -14 Irrigatio Approx. Depth lSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Desfruetion ❑ ,f Well Diameter Sealing Material (top 501 r z t Depth Filler Material.(Below 50'1 -- f f TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) F 4 kF Installation will serve: Residence K Commercial—�lOther Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK -Fl- Type/Mfg Capacity : No. Compartments PKG. TREATMENT PLT.-L] '. f I,Method of DiYl I a (� r __,;,_..Distance to nearest: Well L_..-I roundation�. Property Line ' i OF LEACHING LINE `'❑ Nd &Length of lines r ti-�ot length/size s FILTER BED ❑, Distance to nearest: Well. Foundation Property Line s _ 7 t .� i SEEPAGE PITS l 1*-Depth Size - N mbar ff � AVFobundation SUM S 0 Distance to near sf: Well - --Property Line DISPOSAL PONDS ❑I hereby certify thatI have prepared this application arid 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 law_ s 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,l shall employ persons subject to workman's compensa- i tion laws of California." t The applican ustrcall for ailz' red inspegfions. Complete drawing on reverse side. Title: J Date: I Signed X „ FOR DEPARTMENT USE ONLY f Application Accepted by Date Area 1 Pit or Grout Inspection by Date Final Inspection by. Date Additional Comments; O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 °` '• Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009;%Stk., CA 95201 ,.r FEEAMOUNT DUE AMOUNT REMITTED GK RECEIVED BY HATE PERMIT'NO. ! INFO CASH 9 EH 1426 ! 4 k �"