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jl vt vF t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES TYEAR 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. 1 Job Address / City Lot Size gG X-rl U PM � �� Phone Owner's Name Address C36 Contractor Co' License No.,A- Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS 11Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private -❑ Gravel Pack ❑ T Type of Casing—. Specifications (1 Public ❑ Other - . Delta Depth of Grout Seal ! Type of Grout V I I Irrigation Ap epth i I Eastern Surface Seal Installed by-- Repair y Repair Work Done ❑ e of Pump H.P. State Work Done _ Well Destru n ❑ Well Diameter Sealing Material It 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l I 'DESTRUCTION l No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial _.— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Mme" Water table depth r SEPTIC TANK Type/Mfg Capacity F No. Compartments PKG. TREATMENT PLT. p IT . Method of Disposal ' Distance to nearest: ,Well Foundation Property Line _ LEACHING LINE ❑ No. & Length of,lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS f I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line_ DISPOSAL PONDS ❑ 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 Local Health District. 3. 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." 1' The applicant pvqt call f all required inspections. Complete drawing on reverse side. l Signed X f Tide: Date: FOR DEPARTMENT USE ALY Data q A a Application Accepted b �7 Pit or Grout Inspection by Date Final Inspection by Date Additional Common d ❑ Stk 466-6781 ❑ Lodi 369-3V1 ❑ Ment 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C KSH RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13-24 1REV.t/n 51 EH 14-2e v