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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE:; STOCKTON, CA y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. ' �' Er Job Address _ City Lot Size 3 PM j . _ 2 0 Y .✓ 'aPhone �~ Owner's Name Address Contractor Address L-icense No., Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO_N ❑ PUMP INSTALLATION ❑ SYS EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR1C LTUR WELt OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing Specifications ❑ Public ❑ Other ❑ Delta Dept of Grout Seal Type of Grout ❑ Irrigation f --Approx. Depth ❑ Eastern Surfac eal Installed by O 4 Repair Work Done ElType of Pump H.P. State Work Done Well Destruction LJ ') Well Diameter Sealing Material (top 50 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is W available within 200 feet.) Installation will serve: Residence Commercial, Other ti f Number of living units: Number of bedrooms Il Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V Type/Mfg CapacityLip- 00 t No. Compartments PKG. TREATMENT PLT. ❑ IMethod of Disposal Distance to nearest: Well Foundation Property Line I f LEACHING LINE ❑ No. &iLength of lines 5 Total length/size FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth, Size Number SUMPS ❑ Distance to neatest: . Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. }. - ` 46' 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 taws 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 la s of California." app ca must call for all required inspections. Complete drawing on reverse side i t , Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b i, Date Final Inaction by Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 823-7104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f 1 I I FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. i INF i' + EH 13-241REV.1i 851 ,C _.�b �a - �� I1 - � EH W28