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APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT (y tl 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 City . Lot Size PM Owner's Nam Addressf Phone Contractor 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. FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications rl Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Do Type of Pump H.P. State Work Done_ Well De tion ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 IVIZ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTII i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence______ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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. 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." Th plicant must call for all required inspections. Complete drawing on reverse side. ry Signed X - _ Title: Date: T may] FOR DEPARTMENT USE ONLY Application Accepted by _ _ / z ( ` ��s�b' �J Date -7-7—Y7 Area Pit or Grout Inspection b Date Final Inspecliq y Date Additional Comments: �� (^ ❑ Stic 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-" ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / L(/jilg�rlr9JrJ M&FEE INFO AMOUNT DUE AMOUNT REMITT ED CASH RECEIVED BY DATE PERMiT N0. EH 13-241REV.1/N5f !vV 2�. �VKf!�J � tom'' 1_ �� EH 142e J t '-' t