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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "' ""'"'4t 1601 E. HAZEL T ON AVE.,.STOCKTON, CA , Telephone (209) 466-6781 PERMIT EXPIRES 9 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 made H compliance with San Joaquin County Ordinance No.549 far sewage or No. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . � s application is Job Address n' i City S,:L.h,�.-1{[+of Size PM Owner's Name Address a Phone Contractor 5 Address /XC TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone PUMP INSTAL ION ElWELL REPLACEMENT L_' DESTRUCTION E3DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR 1-1 OTHER El LINES D SAL PROP. LINE FLD. FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL P BLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M toi Dia. of Wel! Excavation � ❑ Domestic/Private ❑ Gravel PackDia. of Well Casing ❑ Public c Type of Casing ❑ Others„ �❑ Delta _ Depth of Grout Sea! Specifications El Irrigation _p,ppr epth EJ Eastern — Type of Grout Surface Seal installed by - Y Repair Work Done ❑ Type of ump Well Destruction ❑ H P State Work Done Well Diameter Sealing Ma ial Itop 50') Depth Filler Material f w 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Commercial Other , Installation will serve: Residence available within 200 feet.) � Number of living units: k Number of bedrooms Character of soil to a depth of 3 feet: r SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity# No. Compartments Distance to nearest: Well. Method of Disposal Foundation ^ Property Line LEACHING LINE ❑F No & Length of lines " FILTER BED ❑�", Distance to nearest: Well Total length/size }. Foundation Property Line SEEPAGE PITS ❑" Depth + SUMPS Size Number ❑ Distance to nearest: Wep _ DISPOSAL PONDS ❑ Foundation Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San rules and regulations of the San Joaquin Local Health District. Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature r certifies the fallowin permit is issued, I shall not � g:"I certify that in the performance of the work for which this permit is issued;Ishan-employ persons subject to workman's compensa- cerl laws of California." The applicant call for all required in pections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Appiicatiori Accepted by Z� r Data �f` Area Pit or Grout Inspectio y Date Fin 1 Inspection by a—go— 5� , Additional Comments:-' ( ' �!� Date ❑ Stk-"466-6781 ❑ Lodi 369- 1 ❑ Manteca 823 7104 Applicant Return all copies to: Environmental Health Permit/Servi s 1601 ❑Hazel o eTracy 6p50 Box 2009, Stk., CA 95201 I FEE' INFO AMOUNT DUE A UNT REMITTED y CASH RECEIVED BY' PATE PERMIT'NO. + EH 13-24(REV,1/"5) EH 1429 �J _`� .„,��Z?.