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I APPLICATI0N.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �p ?G Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tip \Z f " x (Complete-in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ install the work herein described. This application ' 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 J local Health District.__. p is `] 1 Job Address c�C - a' i City Lot Size Owner's Nam PM� ' ddress r Phone Contractor k Address TYPE OF WELL/p p. NEW WELL ❑ License No. phone PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION Eli SYSTEM REPAIR ❑ } 4 DISTANCE TO NEAREST: SEPTIC TANK OTHER C1 t t SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE r OTHEA LIMPS TYP PROBLEM AREA CO ❑ Industrial EJ Open Bottom ~- N SPECIFICATIONS - Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack racyDia. of Wel! Casing ❑ Public of Casing ❑ Other ❑ Delta Depth of r al Specifications ❑ Irrigation prox. Depth w ❑ Eastern Type of Grout i Repair Work Done ElType of Pump H P -Surface Sealllnstalled by Well Destruction ❑ Well Diameter - State Work Do , Sealing Material {top 50') Depth TYPE OF Filler Material (Below 50') SEPTIC WORK: NEW INSTALLATION ❑ REP VAD 'ION Q DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence, available within 200 feet.) Commercial_ Other Number of living units: Number"of bedrooms r Character of soil to a depth of 3 feet: 9 SEPTIC TANK ❑ Type/Mfg ,,./ Water table depth PKG. TREATMENT PLT. L1Capacity 5. _ No. Compartments Distance to nearest: it f Method of Disposal Well Foundation A _ 2 Property Line LEACHING LINEI ❑ Na. & Length of lines _ FILTER BED ❑ Distance to nearest: Well.....__ '+ Total length/size Foundation Property Line SEEPAGE PITS Q Depth SUMPS Slee unNumber . ❑ Distance to nearest: . Well. Fodation DISPOSAL PONDS ❑ Property Line 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 an rules and regulations of.the San Joaquin Local Health District. d 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, 1 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 for all re fired inspections. Complete drawing on reverse side. A Signedyti Title: lJ 3 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ��=``3"'V� Pit or Grout Inspection by � Area Final a Date � � ��' Oa nal Inspection by Additional Comments: ❑ Stk 466-6781 ❑ 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 95201 FEE �AMOUNT DUE AMOUNT REMITTED K - 4 INFO SH RECEIVED BY' DATE. PERMIT'NO. + EN 13-24(REV. EH 1428 e �