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APPLICATION FOR PERMIT SAN. JOAQUIN LOCAL HEALTH DISTRICT C 1601 E. HAZEL i ON AVE., STOCKTON, CA J Y� Telephone (209) 466-6781 NO ` cid Il PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N4 t4 (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 ` ' ��' w .City Lot Size PM Owner's Name Address /�� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION tE�34TUBE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE FICATION ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifications ❑ Public Other i Q Delta Depth of Grout Seal Type of Grout ❑ Irrigatio _—Approx. Depth ❑ Eastern Surface Seal Installed by } Repair Work Done ❑ Type of Pump W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ! Depth 1f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION 0- DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) JI Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms # Character of soil to a depth of 3 feet: 7 Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments { PKG. TREATMENT PLT. ❑ { 1Method of Disposal Distance to nearest: f Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines. Total,length/size } v i - FILTER BED ❑ Distance to nearest: E Well Foundation 4 Property Line SEEPAGE PITS ❑ Depth f Size Number I SUMPS ❑ Distance to nearest: Well Foundation I Property Line DISPOSAL PONDS ❑ r; 1 I hereby certify that I have prepared this application and that the work will he 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 al to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that i'n the performance of the work for which this permit is issued,,I shall employ persons subject to workman's compensa- tion laws of California." } -- - --" — - - -' - L The applicant must call for all required inspections.y Complete drawing on reverse side. Signed X 9 44� Title: 6Ay11^1-C_ I 'Date: 3 r17— �-:;z OR DEPARTMENT USE ONLY t Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by ` Date Additional Comments: a e ❑ Stk 466-6781 ❑ Lodi 369 3621 0 Manteca 823-7104 ❑ Tracy r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N. INFO AMOUNT DUE AMOUNT REMITTED,] CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,I/BS) � , O C_ /1 EH 1426