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t APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON 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 e made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City of Size PM I Owner's NamSW � Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION C1 SYSTEM REPAIR L] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . LINE FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS ❑ Industrial ❑ Open Bottom a a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T sing Specifications ❑ Public ❑ Other' Delta Depth of Grout Sea Type of Grout ❑ Irrigation _ A Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑` pe of Pump H.P. State-Work Done Well Destruc' ❑ Well Diameter Sealing Material {top 501 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT.ION (No septic system permitted if public sewer is x available within 200 feet.) Installation will serve: Residence_ Commercial_ Other [ Q 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines s Total lengthlsize 5 FILTER BED ❑ Distance to nearest: WellFoundation Property Line SEEPAGE PITS ❑ Depth Size 'Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ !I 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 I 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 cal for all required in pectin Complete awing on reverse side. �/ Signed Date: O FO DEPARTMENT USE ONLY Application Accepted by Date �/ / Area ` Pit or Grout Inspection by Date Final Inspection by pie - Additional Comments: L'r Ina, ke ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Man eca 823-7104 ❑ Tracy 835-6305 /11 Applicant- Return all copies to: Environmental Health P rmit/Services 601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 GUT -o L7 b4lrFEE _GI INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMrr'NO. + EH 43-24 MEV.1/857 EH 14.284,1 i