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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 .. PERMIT EXPIRES T YEAR FROM DATE ISSUED 1 (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 Address 4�.e1J !r l� City Lot Size PM Owner's Name Address Phone Contractor _ Address ��b -""""`"` _ License No.� .Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJPUMP INSTALLATION-O----.-- -»----�-.--SYSTEM REP-AIR.[ay—_OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P.-LINE FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC CiFICATIONS El Industrial C1 Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ • Type of Casing Specifications v f l Public ❑ Other [ Delta Depth of Grout Seal i. Type of Grout I Irrigation- ox. Depth I 1 Eastern Surface Sl Installed by { _ Repair Work DoneL7 ypeype of Pump H.P. State Work Done Well Destruction �'❑ Well Diameter Sealing Material Itop 501 j r V Depth � FillerMa�eTial"ISglo`w TYPE OF SEPTIC.WORK: -NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:` Residence_ Commercial= Other 41 Number of living units:. !Number of bedrooms Character of-soil..to_a.depth of 3 feet: k Water fabi& depth SEPTIC TAN K- "❑ Type%Mfg + Capacity f s No. Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation _ ' Property Liner LEACHING LINE ❑ No. 8r Length of lines Total length/size ' FILTER BED ❑ Distance to,nearest: Well r- ,Fou ndation �" "—Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. C 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." 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." p The applicant st call for all required ' sp`ecti ns.Complete drawing onnrreverse side. Signed X Title: r Date: FOR DEPARTMENT USE ONLY, Application Accepted by Date Area Pit or Grout Inspectionrby Date Final I spection by Date Additional Comments: I I i 5 v- r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r ,P Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95204, b INO FEE AMOUNT DUE AMOUNT REMITTED C SFRECEIVED BY GATE EH 13 2A IREV.r i n 51 �1 � t &EH,1-2e // W 1 4 �--� -P -a