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APPLICATION FOR PERMIT s f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA t 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 andlor 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 a City Lot Size PM Owner's Name dress Phone Contractor Address license No. Phone TYPE OF 11 LL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑-- t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ .,t OT DISTANCE TO N EST: SEPTIC TANK" SEWER LINES DISPOSAL FL PROP. LINE i OUNDATION AGRICULTURE WELL OTH LL PITS/SUMPS t INTENDED USE TYP WELL PROBLEM AREA CONSTRUC PECIFICATIONS 0 Industria! ❑ Open Bottom 11Manteca D- ell Excavation Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing '- Specifications Q� f7 Public f=i Other Delta Depth of Grout Seal --Type of Grout \ I I Irrigation prox. Depth I i Eastern Su a al Installed by - Repair Work D Type of Pump H.P. to Work Done Well De ruction ❑ Well Diameter Sealing Material {top 501 Depth _ Filler,Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f I DESTRUCTION Ilk (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence— Commercial_____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg -Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of tines k 1 Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS [I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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�ecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ; certifies the following: "I certify that in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica us "allrepdir—ed r coons. C plate drawing on everse sidre.�� /p F itle: ► v Date: ' ! / ;4 1 Signed. f i FOR DEPARTMENT USE ONLY Application Accepted by Date l Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' PS.7� �" P b� �I Q W ❑ 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, Stk., CA 95201 I FEF INFO AMOUNT DUE f AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH13.241REV.t/H51 3s_ 00 lira S'1w1�-7—ljq5-77 EH 14-28