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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Job Address V rn�— City Lot Size ��PM �/ .14.x- �1f.. �I� ..Phnna. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'It PUMP INSTALLATION ❑ SYSTEM REPAIR Cl 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 © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public Ll Other Cl Delta Depth of Grout Seat Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. . State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence_ Commercial_ Other Num -oing units: Number of bedrooms (� Character of soil to th of 3 feet: Water table depth SEPTIC TANK ❑ fg city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal distance to nearest: Foundation Property Line LEACHING LINE ❑ No. ngth of lines Total length/size FILTER BED ❑ rstance to nearest: Well Foundation SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISP 'LPONDS ❑ I he eby 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 followi : "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 Calif ia." The applicant m t call for all require inspections, Complete drawing on reverse side. A Signed Title: ..tom,_ Z Date: Z 2 U FOR DEPARTMENT USE ONLY Application Accepted by Date _ - � Area Pit or Grout inspecti y Date Final Inspection by DateL�� 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + EH 13-24(A EV.I/H5) EH 14-26