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V APPLICATION FOR PERMIT �� r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA �,✓k Telephone (209) 466-6781 [PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i 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. e . Q�� V City Lot Size PM Job Address II Owner's Name rAddress 3 Q Phone Contractor /� Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "DISPOSAL�FLD-. -�ROP. LINE FOUNDATION AGRICULTURE WELD' _ �OTHER- ECLY PITS/SUMPS 1 rr � INTENDED USE TYPE OF WELL PROBLEM AREA`CONSTRUCTION SPECIFICATIONS fl Open Bottom ❑ Mante ah Dia. of Well Excavation Dia. of Well Casing El Industrial P Type of CasingSpecifications L] Domestic/Private ❑ Gravel Pack racy r'l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout roxDepth I Eastern Surface Seal Installed by f� i t Irrigation pp : - s V J Repair Work Done Type of Pump H.P. State Work Done Well Oear� ❑ Well Diameter Sealing Material (top 50'1 m I _ - - 4:'- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I. 1 DESTRUCTION (No se ttic systthinem retitled if public sewer is availaInstallation will serve: ,Residence_ Commercial— Other O I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK El Type/Mfg 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: Wel! Foundation Property Line t.l.l SEEPAGE PITS 4` `1-1_Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS ❑ I hereby-certify that-1 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 shalt 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." ` v The applicant must c all required ins ions. Com to drawing on reverse side.. 1 1 Signed X Title: . /( � Date: FOR DEPARTMENT USE ONLY f,rt Application Accepted by Date �� Area L i Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: r t ❑ 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. l3ax 2009,-Stk-CA 95201�� t FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY PATE PERMIT NO. INFO . EH 13-24(REV.I/n 51 EH 1428