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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Counjy 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 /� rty Lot Size PM Owner's Na U"r l/�- Address _ Phoneme'c `A 3 �9a License No. 4�E& Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑. DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIOTHERi DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES (/ `DISPOSAL FLD. PROP. LINE FOUNDATIQN. AGRICULTURE:!Z4L Y. OTHER WELL_ PITS/SUMPS ��f INTENDED USE VYPE-OFW tlL"- 48LEMAREA CONSTRUCTION SPECIFICATIONS ^ ❑ Industrial --- ' O-AAanteea- -tea: of=WeN-€xcavation Dia. of Well Casing >- [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Citsing Specifications _... _. _ F] Public F1 Other 1-1 Delta Depth of Grout Seal /� 'Type of Grout _ I I Irrigation Approx. Depth I I Eastern "' Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done 'G Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ,i�� %_r , '� ` 4� TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 1 to n will serve Residence_ Commercial__ Other Number of living units: Number of bedrooms Character of soil to a depth of:3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT,PIT ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of fines Total length/size .l FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll 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 become subject to workman's compensationiaws of California."Contractor's hiring or sub-contracting signatu certifies the following: "I certify that in the performance of the work for which this permirj's issued,I shall employ persons subject to workman's compensa- tion laws of California." - The applicant rnt7`st I equi ons. Complete drawing on rev rsq side. Signed X Title: - >> — :fit= l' .. A � Date: 1 �,�- /} FOR DEPARTMENT USE O LY Application Accepted by / 11�7✓_ 4Z� �✓ Date f) Area 1 Pit or Grout Inspection by Date Final Inspection by Additional Comments: l:A / � _!.(1' ZZ ❑ Stk 466-6781 ❑ Lodi 369-3621 C1Manteca 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 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH13-241REV.rinS) �L2. EH 14-26 a