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VS. APPLICATION FOR PERMIT �j✓ 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. i Job Address rJ City Lot Size�✓�y ' PM Owner's Name Address �� "/ Phone Contractor /J/ Address License No. Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTirTANK SEWER LINES DISPOSAL FLO, P. LINE FOUNDA AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private = .0 Gravel Pack Tracy Type of Casing cifications M Public Cl Other {-1 Delta Depth of Grout Seal Type of _ I I lrrigation pprox. Depth f I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruc n ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l 1 DESTRUCTION1/iN0 septic system permitted if public sewer is available within 2oD 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 f—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 ❑ 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. Homeowner 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."Contractors 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 a to d inspections. Complete drawing on verse side. Signed X Title: ��..._,,..— Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection $4 Date Final Inspection Date J Additional Comments: r_ ! � / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 5 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 -CK RECEIVED BY DATE PERMIVNO. r EH 13-24 IH EV.t/A51 EH 14-26 cJ . I