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t a G APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 11 rr Jab Address CitLot Size PM Owner's Name 1 Address 42 Phone C1 ` t Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications r'1 Public ❑ Other E [1 Delta Depth of Grout Seal Type of Grout — r— I 1 Irrigation prox. Depth' '€ I Eastern Surface Seal Installed by Repair Work Done Type of Pump r- 4 H.P. State Work Done_ Well Destr n ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION. INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_' ;Commercial Other - Number of living units: Number of bedroomsVA Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG. TREATMENT PLT, ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines. 4 Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` 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 agents 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 pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." s: The applican t c II for all required ins c�io . Complete drawing on reverse side. r� Signed X Title: Date: C3L� FOR DEPARTMENT USEONLY Application Accepted Inc, Date Are 4 Pit or Grout Inspection Date Final Inspection by Datt# Additional Comments: + ❑ 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. Box 2009, Stk., CA 95201 FEE1 INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED 9Y DATE PERMIT•NO. + Eli 1241REV.1/951 EH 14-4-28