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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. .HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I . (Complete in Triplicate) ' F ppli tion 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 ma in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of rhe San Joaquin cal Health District. Job Address S Cit Lot Size PM q i.� Owner's Name Address Phone 1 Contractor !• icense No. Y Phone ss TYPE OF WELL/PUMP: EW WELL / WELL REPL CEMEN 1:1 DESTRUCTION ❑ PUMP-INSTALLATION Z11-11 1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of-Well Casing ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl P/ub1�c n Other f_1 Delta Depth of Grout Seal Type of Grout--.—., t M1Vfrrigation Approx; e h I gastern - Surface Seal,Insialled by - Repair Work Done ❑ Type of Pump; P. State Work Done _ Well Destruction ❑ Well Diameter T �/ Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW IN A LATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is a 4 available within 200 feet.) Installation will serve Residence_@ 'Commercial Other Number of living units: Number of bedroom Character of soil to a depth of 3 feet:`" Water table depth I SEPTIC TANK ❑ Type/Mfg! = r Capacity No. Compartments / I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size i FILTER BED T`.❑ Distance to_nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth '.Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �' F 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 fallowing: "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 call f r all uire inspec79. tions. Complete drawing on rse s'de. Signed X Title: Date: OR DEPARTMENT USE ONLY _V7 Application Accepted by Date 2 U/—�C1 Area ' Pit or Grout Inspection by Date Final Inspection by !� Da[ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. j INFO ��\\ +.EH 13-241RE'V.1/H5) �5a C5 EH 14-26 {