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APPLICATION FOR PERMIT S y SAN JOAQUIN LOCAL HEALTH DISTRICT NO� 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 �Ip 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.aC�`g Job Address ' &46� _ City r of Size PM Owner's Name M ' Address ` V / Phone Contractor01 ddress License Noy � �,F Phone ! U:0'2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M eca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tar Type of Casing Specifications F] Public 11 Other 171elta Depth of Grout Seal Type of Grout I I Irrigation —_Approx. Depth t Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITI 1 I D TRUCTION I I (No septic system permitted if public sewer is ilable ithin 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: t r le depth SEPTIC TANK ❑ 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 ,d FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 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 applican ust call fquired ins ctions. Complete drawing on reverse side. Signed X Title: Date: D FO DEPARTMENT USE ONLY Application Accepted by Date ~�� Area Pit or Grout Inspection by Date Final Inspection by Date d r 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 IFEE O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEPERMIT NO PERMIO. s EH 13-21(flfV.t i 9 s] LV 5,O D G`C) + r^ EH N-26 ll 1 ti o