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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I . PERMIT EXPIRES TYEAR FROM DATE ISSUED r (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. Job Address City Lot Size PM J _I j / T✓ �_� Owner's Name!�/✓rTv t Address C Phone ! Contractor,k } Address License No. Phone ,TYPE OF WELL/PUM . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA ON ❑ SYSTEM REPAIR ❑ OTHER ❑ 3iD1STANGE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE �`bTFfER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLE REA NSTRUCTION SPECIFICATIONS r i ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy pe of Casing Specifications i j + f l Public-- i 1 Other fes^ ❑ Delta Dep of Grout Seal�� f Type of Grout M1. I I lrriyation r�.-Appr eplh I I Eastern Surface a! In by t Repair Work Done ❑ Typ Pump H.P. 5tateWork Done_ C { Well Destruction ❑ _ ll Diameter 4 Sealing Material Itop 50'i ' } - Depth Filler Material (Below 50 E r T 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f,I DESTRUCTIO `.iNo septic system permitted if public sewer is 1 f ailable within 200 feet.) t W j1f Installation will serve: Residence Commercial Other Number of riving nits.- Number of bedrooms 4 Character of soil 3 feet: t ,i Water-table-depth* "! #r ! SEPTIC TANK — Type/Mfg Capacity No. Compartments PKG. TREATMENT PUT.�T. � � Method of Disposal l Distance to nearest: Well Foundation Property Line 9 LEACHING LINE ❑ Na. & Length of lines Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: .. Well Foundation Property Line E r ! \ SEEPAGE PITS I 1 Depth t Size _ Number f SUMPS CI Distance to nearest: Well Foundation Property Line ! DISPOSAL PONDS ❑ 3 s I hereby certify,that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law's, and r rules and regulations of the San Joagi in-Local,Health�District: ----- ----——— F i Home owner of licensed agent's signature certifies the following:-1,certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ai to become subject to workman's compensatioro laws of California." Contractors hiring or sub-contracting signature r certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion-laws.-of. California:" s. The applica ust call for ail required inspections. Complete drawing on reverse side. I � Signed Tide: Date: r . a FOR DEPARTMENT USE ONLY ? Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. INFO ]`{�] / ](� Ql� 12b a.EH 13-24MEV..t1951 `�. �/}f� - �j .✓ --.} V�" EH 14-29 VV