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N- APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,,.STOCKTON, CA Mo �0 � Telephone(209) 466.6781 . PERMIT EXPIRES'1 YEAR FROM.DATE-r'SSU ED (Complete in;Trjplicate):,, 4;:rr7. t 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 sewageor.No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address <7 r�? City Lot Sizewx.l PM YlOwner's Name " Address _ G Yg* Phone Contractor Address r License,No- Phone TYPE OF,_ .LL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRU PUMP INSTALLATION ❑ "4 SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE -FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal' Type of Grout ❑ irrigation 9 _Appy . Depth ❑ Eastern SurfaceSealInstalled by Repair Work Done ❑ Type Pump H.P. _ State Work Dane 1 Well Destruction ❑' II Diameter '"" - �' Sealing Material {top 50') " Depth 1 Filler Material (Below 601 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other F 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 3 PKG, TREATMENT PLT. ❑ x Method of Disposal Distance to nearest: Well Foundation Property Line j f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth Size Number' SUMPS ❑ Distance to nearest: Well t FoundationProperty Line DISPOSAL PONDS EI { � r 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 fnr�which this permit is issued, I�shall employ persons subject to workman's compensa- W tion laws of California." i } 1 r The applicant m all for all requir inspections. Complete drawing! on reverse side" I Signed X Title: Date: DEPARTMENT USE ONLY ^-� Application Accepted by �k Date `�1` ! Area i Pit or Grout Inspection by Date Final In ction by o� Date Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 r-,la Ve�l 6-6y- LNC FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY. DATE PERMIT"NO. ; INFO CASH + EH 13-241REV. EH 1428 i