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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED {Complete in Triplicate) r b made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is heie made in compliance ith San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distric 1 Job Address S/ EI Cityh o Size PM Owner's Name ddressPhone ContracttBwk& Ery1f. Address4-L4_11.2 License No. Phone TYPE OF.WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ INSTALLATION•❑ SYSTEM REPAIR ❑- _: OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ArCRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trsing Specifications F] Public f 1 Other eltarout Seal Type of GroutI I Irrigation Approx. Depth I I Easternal Installed by Repair Work Done ❑ Type of Pump H. . State Work Done 01 Well Destruction ❑ Well Diameter Sealing Mate ial (top 50') _ Depth Filler Material (Below 50') 1� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 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 ti Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Na. C mo p�rtments -� t PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of tines 7Z Total length/size FILTER BED ❑ Distance to nearest: Well-- Foundation Property Line _ SEEPAGE PITS i I Depth Size Number SU 'S CI Distance to nearest: 'Well Foundation Property Line DISPOSAL P NM—❑ i 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." The applicant must call for all required inspections. Complete drawing n reverse side. �7 72 Signed Title:U Date: r r-- —0 FOR DEPARTMENT USE ONLY 'J�3 — Application Accepted by ` Date 8'—� 7 Area T Pit or Grout Inspection by at Final Inspection by Data Additional Comments: r� tr ❑ 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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. r EH13-24(REV.1/N 5) `�� /.S EH 14-2e ��...,,,lll IVVJ