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APPLICATION FOR PERMIT 15`a 1-6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA -z Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Ii 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. S 1�+ t 10 Job Address r City Lot Size PM N Owner's Name V ddress ► Phone / L Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE 1 C4 FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS „ INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS L] Industrial ❑ Open Bot tom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications w i I'i Public Cl Other I ❑ Delta Depth of Grout Seal Type of Grout _ n i I I Irrigation proxi Depth I I Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done Well Destr ❑ Well Diameter Sealing Material Itop 50'j Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l (No septic system permitted if public sewer is O available within 200 feet.) Installation will serve: Residence' Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet.! Water table depth f SEPTIC TANK ❑ Type/Mi Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 il a SEEPAGE PITS I I Depth `I Size Number SUMPS ❑ 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, 1 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." t The applic t must ca for all required ins ctions. Complete drawing on reverse side. ignedTitle: Date: !!�d I FOR DEPARTMENT USE ONLY Application Accepted by Date Area U Pit or Grout Inspection I Date Final Inspection by ' Dateins Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca a2 104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Petmit/Servicas 1601 E./JHazelton Ave., P.D./Box 2009, Stk. CA 9 01 �40 , f' Gp uL��rF FEE AMOUNT DUE A OUNT REMI D CAS RECEIVED BY DATE PERMIT N INFO O. + EH 13-24 IREV.t/n 51 � ,d ,O L.1 EH 14.2e u �J {