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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tComplete 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 welllpu p and the Rules and Regulations of the San Joaquin Local Health District. 60Job Address City ! Lot Size PM Owner's Name ddress Phone Contractor/ - _Address.+ -� M1 License No��--Phone YI /d TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 0 EM AREA CONSTRUCTION SPECIFICATIO'µ NS"�" ' a ❑ Industrial El Open Bottom ❑ Ma eca Dia. of Well Excavation Dia. of Wel! Casing it ❑ Trac Type of Casing Specifications i 11 Domestic/�rivate 0. avell Packf-i Public '3 her F'-Delta Depth of Grout Seal Type of Grout I I Irrigation .M f ..Appro Depth I I Eastern Surface Seal 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 b0') ie r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IV-DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living.units: k Number of bedrooms f� Character of soil to a depth)of 3 feet: Water,table depth SEPTIC TANK ❑ 'Type/Mfg JeCa city No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal I'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ iI�No. & Length of lines Total length/size FILTER BED ❑ pistance to nearest: Well SO t Fo dation Property Line SEEPAGE PITS I I i Depth Size Num r SUMPS Ll Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS D 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. t 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 applicapf must call r all re ired inspections. Complete drawing on reverse side. Signed X Title: rQZ� _ _ date /�� • { FOR DEPARTMENT USE ONLY Application Accepted by Dale4' . Area Pit or Grout Inspection by Date Final Inspection by Date ltf' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. I +.EH 13-24(REV.tirtisr l EH 14-26 I ( G LLL i