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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 N1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 / /�/ y0 City Z of Size PM r wner's Name /✓ , `0` � ( i��L f��e A dress f/ T SJ �( -�V T� Phone Contractor ,J AZI Address ! !) /Tl/��°2 �r License No. Phone�� YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P LEM ARE CONSTRUCTION SPECIFICATIONS ❑ Industrial - El Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr y Type of Casing Specifications M Public Cl Other Delta th of Grout Seal Type of Grout _ A: I I Irrigation Approx. Dept 1 1 Eastern Surfa Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Nt Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within-200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedroom"s,.,_..... Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments, oc, PKG..TREATMENT PLT. ❑ Method of Disposal ( \ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total,length/size O FILTER BED O Distance to nearest: Well Foundation Property tine SEEPAGE PITS 11 Depth Size Number 0 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 compensation laws of California." Contractor's 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." The applican must call for A required i54pections. Complete drawing on reverse ide SignedTitle: Wiz' Date: ^ r/ n t RTMENT USE ONLY v_ Application Accepted by Date ' *' Area Pit or Grout Inspection by Date Final Inspection by Date . Additional Comments: 25� ❑ 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 FEEINFO MOUNT DUE AMOUNTREMITTEDCK RECEIVED BY DATE PERMIT-No. a.EH 13-24 IREV.1/N 5) , � ,3-s �✓'-� A e � ••�� 1 C EH 14-26 `�-/