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APPLICATION FOR PERMIT / G t �, SAN JOAQUIN LOCAL HEALTH DISTRICTafl T �� 1601 E. HAZELTON AVE., STOCKTON,.CA �—�_ � ✓1'1, 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. ac If Job Address � Cit Lot Size PM Owner's Name#�A—L S v/L Address / / U " t L Phone Contractor S � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS _r INTENDED USE TYPE of"WELL—"-'i fi08LEM AREA"CONSTRUCTION'SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing Specifications r * f l Public Cl Other n Delta Depth of Grout Seal Type of Grout ✓��- -- I I irrigation _ —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION f I ,_DESTRUCTION I I INo septic system permitted if public sewer is " available within 200 feet.) In tion will serve: Residence_ Commercial_ Other Number o nits: Number of bedrooms Character of soil to a de 3 feet: Water table depth SEPTIC TANK Ll Type/ Capacity ompartments PKG. TREATMENT PLT. ❑ k �a. Method of Disposal Distance to nearest: Well foundation, Property Line LEACHING LINE ❑ ength of lines Total length/size FILTER BED ❑ Distance to nearest: Well ;Foundationerty Line SEEP E PITS i I Depth Size Number SUMPS - LI 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 Diltrict. " 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 applicant ust call for all required inspections. Complete drawing on reverse side. Gj j Signed X� / 2'r S / Title: Date: / ~� FOR DEPARTMENT USE ONLY Application Accepted by Date Area I Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVER BY DATE PERMIT'NO. +.EH 13-241pEV.rias, INFO _