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} F APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT .� � ' Yy� E 1601 E. HAZEL i ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 IV PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Il 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. E Job Address 4 a ��._ f-t /// City Lot Size PM Y ' x i Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAgEQENT ❑ DESTRUCTION ❑ PUMP INSTALLATI ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS s - INTENDED USE TYPE OF WELL PROBLE R CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing k ❑ Domestic/Private ❑ Gravel Pack CI Tra Type of Casing Specifications M Public Cl Other Cl D to th of Groirt Seal Type of Grout I I Irrigation --Approx. Depth astern Surfa 'Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (BeIA 501 n , E TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION { I DESTRUCTION (No septic system permitted it public sewer is �J available within 200 feet.) Q ) Installation will serve: Residence_ Commercial— Other r Number of living units: Number of bedrooms lam' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BE¢$ ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth Size r Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. 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.' Tho applicant must call for all req uir d inspe tions. Com late drawing on reverse side. ^ Q .�j. Signed X r— itle: �� -'� Date: - 7—3 5 I //�� F DEPARTMENT USE ONLY Application Accepted by 1�� ., Date_ - y" CX, Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _- 0 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-244REV.r/x513