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' APPLICATION FOR PERMIT / � SAN JOAQUIN LOCAL HEALTH DISTRICT V Z,2, 1601" E. HAZEL T ON AVE., STOCKTON, CA ' 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 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. - 1�1�LQ2. �• Aya lft �� City Lot Size •``^� PM LJobdress — Name ss Phon«ftor Address License No. Phone_ F WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - SA FLD. PROP. LINE FOUNDATI6� A AGRICULTURE ,OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ante. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications M Public ❑ Ot n Delta "Depth of Grout Seal Type of Grout _. - 1 I I Irrigation ..Approx. Depth . I I Eastern ------.Surface Seal Installed by - Repair Work Do Type of Pump AWP:- - - -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION L I DESTRUCTIO ). (No septic system permitted if public sewer is "available within 200 feet.) 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 PKG. TREATMENT PLT. ❑ I',, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r--- length/ size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sze 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 bec me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j certifies the follow' "I certify th in th rmance of the work for which this permit Wissued, I shall employ persons subject to workman's compensa, tion laws of Cali ,The applicant II for all re d tions. Complete drawin ••reverse side. p Signed X Title: Date: " v FOR DEPARTMENT.USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Ins tion by atOF� 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 i FEE MOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT"NO. INFO i EH13-24(REV.tins) 6Z? f tC[�) EH 14-26 'r6 J