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hw • f V APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 welupump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Z C�r City - Lot Size PM .ii Owner's Name Address Phone IM Contractor ;a< Address� � , /IL Licenses Pho TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑_ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLb. FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF4ELL PROBLEM AREA C CTION SPECIFICATIONS ❑ Industrial r ❑.Open-Bottom ❑ Mante Dia. of Well Excavation ! Dia. of Well Casing ❑ Domestic/Private C1.Gravel Pack ffi racy Type of Casing I Specifications (`1 Public I_1Fther Ll Delta Depth of Grout Seal Type of Grout # I Irrigation .. pprox Depth, i I Eastern Surface Seal installed by i Repair Work Done Type of Pump H.P. State Work Done P i Well_Destr ' n ❑ _ We Diameter""` Sealing Material (top 50') € Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11- REPAIR-/ADDITION-1"1--DESTRUCT'10 (No septic system permitted if public sewer is available within 200 feet.) ; Installation will serve: ,Residence"I Commercial_ Other Nufr1'ber.af liv_ing_units:' Number of bedrooms t 1 Character of soil to a depth�ofY3 feet: - Water table depth _iJA r SEPTIC TANK ❑ Type/fVlfg Capacity i No. Compartments PKG. TREATMENT PLT. ❑ , !`r Method of Disposal ' Distance to nearest: Well V Foundation Property Line J� J I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well .Foundation Property Line p SEEPAGE PITS i I ,Depth Size Number ; j SUMPS 0 ' Distance to nearest: Well " '"Fbundatibn Property Line I 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 sidnature i 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." �I ; The applic must call for all.required inspections. Complete drawing on reyorse side. i. r Signed X I Title: Date: f FOR DEPARTMENT-USE ONLY Application A ', r pp Accepted by Date — Area r Pit or Grout Inspection by `'Date' � Final Inspection by ate i Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ERR IEEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT-NO. 13-21(REV.tin5l