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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the SanUoaquin 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. Cit Lot_ Lot Size PM Job Address T C� lZ, f�t �4 Phone Q Owner's Name a�liniP Address Contractor ddress icense No, Phone , r TYPE OF WELL/PUMP: :. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION:❑ PUMP INSTALLATION d SYSTEM REPAIR t3- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON&TBUCTI".SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing El Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal / Type of Grout I I lrrlg .i ation ---Approx. _: I Eastarn Surface Seal Installed-by Repai;v4ork Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION I I (No septic system m permitted if public sewer is availabInstallation will serve: Residence CommerciAl f Other Number of living units: --4— Number of bedrooms jL_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity a No. Compartments PKG. TREATMENT PLT. Elh �r Method of Disposal Distance to nearest: t Well� Foundation /_s __ Property Line LEACHING LINE ❑ No. & Length of lines "' Total length/size FI TER BED ❑ Distance to nearest: Well Foundation Property Line �EEPPAGE PIT I t Depth ..-Size Number t S LlDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared tfiisrapplication and that thq,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 p"it is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."CVractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of,the v4ork for which-this permit is issued,i shallempiloy person's subred tin workman's compensa- tion laws of California." The applicant mkist call for all re-qd inspections. mplete drawing on eras side. r Signed XC, Title: '� Dater FOR DEPARTMENT USE ONLY Application Accepted by Date f ` Area Pit or Grout Inspection by Date Final Inspection by: ` - �µ- Date Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT NO. r EH 13-24(REV.1/851 EH 14-2a