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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 466-6781 r 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 Addressy^^•�C . City -G. tot Size � PM # Owner's Name` ' _ 'Address ,� Phone 36" Contractor .. . TYPE OF WEL /PUMP: License No. Phone. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER I-]FOUNDATION . --� DISPOSAL FLD. PROP. LINE ' AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA ❑ Industrial - CONSTRUCTION SPECIFICATIONS ❑ OPETS/SUMPS _ Open Bottom ❑ Mant Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Dia. of Well Casing ❑ Public y Type of Casing Specifications ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth 'L-1 Eastern Type of Grout Repair Work Done 12 Type of Pump Surface Seal Installed by H.P. E Well Destruction ❑ Well Diameter State Work Done ; Sealing Material (top 50') Depth- ` Filler,Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION' rREPAIRlADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer Y i �/ available within 200 feet,} Installation will serve: Residence--L'T Commercial_ Other`, Number of livingunits.i Y»'"'.T 1{ —�� Number of bedrooms '4 "��-�^-- •-- •��- - ---��- -�. ,,:_-L f Character of soil to a depth of 3 feet: `q { SEPTIC,TANK ' Type/Mfg Water table depth Capacity r' PKG. TREATMENT PLT:❑ ' No. Compartments Distance`to nearest: Well t � Method of Dispo I h Foundation Property Line LEACHING LINE iErNo. & Length of linesf� .FILTER BED "-D-r Distance to nearest: '•^"Well- =�,F Total length/size e r. Foundation.e� C----_ Property Cine } SEEPAGE PITSp^ Depth SUMPS Sizeumber_ } D Distance to.neare'st: Well r DISPOSAL PONDS ❑ Foundation 3 �` . � ! —�--- Property k tJI 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 rules and regulations of the San Joaquin_LocaI Health District. Home owner or licensed agent's signature certifies the following: employ an g "1 certify that in the performance of the work for which this permitjssissued, I shelf not P Y Y 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 must call for all required inspections,.Complete drawing on reverse side. Signed k 4. Title -f ! "Date FOR DEPARTMENT USE ONLY- Application Accepted by Date x.. ._ Area Pit or Grout Inspection by. Date Final Inspection by ��/� Additional Comments: Date _ El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �* f a Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 t: FEE. AMOUNT DUE INFO AMOUNT REMITTED CIC RECEIVED BY GASH DATE PERMIT'NO. + EH 13-24.lREV.1/x51 } EH 1428 �Q • - -