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I APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT `' - 1601 E. HAZE T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 �`� +p•'�•ck 1 F PERMIT 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 L al Health District. F L -Jab AddressCity Lot Size PM Owner's Namey4atot` D/f f — Address Phone 57 Contraclar ��— ` j Address License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL OBLEM AR CONSTRUCTION SPECIFICATIONS 1.❑ Industrial ❑ Open Bottom Cl nt Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private El Gravel Pack El c -Type of Casing Specifications -I Public F OtherDelta' Depth of Grout Seal Type of Grout' I I Irrigation —..Approx.:Dept l I Eastern Surface Seal Installed by 1!F tt6 Repair Work done ❑ Type of Pump " H.P. StateWork Done _ t v 1, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth n Filler Material (Below 50') V TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REPAIR/ADDITION l I DESTRUCTION No septic system permitted if public sewer is `J vailable within 200 feet.] ' Installation will serve: Residence I Commercial Other Number of living units: Number of bedrooms ,.,-. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK T` ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 1 1 Method of Disposal Distance to nearest: Wdll Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size li FILTER BED ❑ Distance.io nearest: ' Well .Foundation Property Line SEEPAGE PITS 1 i Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: '9 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." The applicant est ca tar all required inspecti s. Complete drawing on reverse /side. Signed X ' Title: ti's Date: �� FOR DEPARTMENT USE ONLY , ' Application Accepted by Date `6 Area Pit or Grout Inspection by D F'nal Inspection by Date II; Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6&5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO r CASH + EH 13-24(REV.I/x5) EH 14-26 I