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APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL HEALTH DISTRICT ) �1 ' 1601 E. HAZELTON 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 County Ordina a-No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I �r/ / ./ Job Address city Lot Sizes / PM f Owner' me Address Phona , Contra t - Address !/' Ll dA lU,111) License No. 4LA hone_ TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REP ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC ANK r WERI&LINES � DISPOSAL FLD.' PROP. LINE FOUNDATIONT AG CULTURE r L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec is`of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y -Ty of Casing Specifications i M Public n Other - Delta Depth f Grout Seal Type of Grout _. ry ,.�_ »._ I 1 Irrigation �_Approx. th l 1 Eastern .w Surface I Installed by ! g� Repair Work Done ❑ Type of Pump H.P. State Wotk Done `V i Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depthk f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I-DESTRUCTIO (No septic system permitted if public sewer is s + available within 200 feet.) Installation.will serve: ResidenceCommercial_ .Other Number of living units: ! Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ,Total length/size - } FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS v fa Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,iand rules and,regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following:."I certify that in the performance of the work forwhich 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 f owing: "I ce ify 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 alifornia.', The applica t mus call f all're tr d nspection_. C i g r v se sid$. Signed e. e: 4 PARTMENT USE ONLY Application Accepted by ' Area Pit or Grout Inspection by Date .Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. a EH 13-24(REV.t EH 14-26 T /`J