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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) 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. 6 /� Job Address r�'gr/ � __ City//Q�MP45 Lot SizePM Owner's Name �er_cl � Address Phone Contractor Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -1TS1SUNaPS INTENDED USE TYP ELL PROBLEM AREA CONSTR FICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel! ❑ r Type of Casing— asing Specifications f'1 Public Other C Delta th of Grout Seal Type of Grout I I Irrigatio _-Approx, Depth I 1 Eastern Surface Installed by Repair Work Done ❑ Type of Pump H,P. fate Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50') ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONX DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 'A Commercial_ Other - - 16 Number of living units: Number of bedrooms Character.of soil to a depth of 3 feet: ,S.ZZ Y C.fez / Water table depth SEPTIC TANK LNC Type/Mfg Capacity /_043 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �� Foundation Property Line LEACHING LINE X No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foun tion 0 f Property Line -� SEEPAGE PITS I,�- Depth v2-7 Size A_.. Number SUMPS ❑ Distance to nearest: Well Foundation Property Line lZel 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 T1 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: "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." The applicant mus,cal sf r alt requi -rnspectr ns. Complete drawing on reverse side. Signed X Title: d� �'� Date: FOR DEPARTMENT USE ONLY Application Accepted by / Date �2�� Area for Grout Inspection y Dat �076"� i Final Inspection by � ,P��a'�-6i�—�� Oate 6 T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE (� PERMIT'NO. +.EHt3-24 IREv.r/x 5f 9 01 EH 14.26 l