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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - ( .,(Complete in Triplicate): n; Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe. 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.w Job Address Or City Lot Size PM, Owner's Name Address /mT Phone Contractor 1 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— ' r� I t FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done_ Well De n ❑ Well Diameter Sealing Material (top 501 F Depth Filler Material (Below 501 TYPE OF SEPTIC WORKl�, EW INSTALLATION ❑ REPAIR/ADDITION 15 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation willlerveidence, Commercial Other f' Number ofdiving!units, Number of bedrooms F Character ofd oho a depth of 3 feet: Water table depth ` SEPTIC TANK Q 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PL,T ®� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ IVo. & Length of lines Total length/size FILTER BED ElDi ance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance fonearest: Well Foundation Property Line DISPOSAL.PONDS ❑ ` 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 rmit 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 I certifies the following: "I certify that in the performance of the work for wtiich this permit is issued,I shall employ persons subjeJt to workman's compensa- tion laws of California." � fi The applicant must call for all required + s. Complete drawing on reverse side. Signed X t l 3 F [LEPARTMENT.USE ONLY I LL, r Date „ ? Area i Application Accepted by _ , Pit or Grout Inspection Date Final Inspection by Da Additional Comments: / i ❑ Stk 466-6781 Lodi .369 3621 ❑ Monte 823 7104 ❑ Tracy 835-6385 Applicant- Return'all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 96M0 l ` FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT•NO. INFO r Q a(� /J 7 + EH 13-241REV.1ix 5) � �C4 Vv 1(Jb \ �{(l.r fr EH 14-26 ..