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Z � APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 &I City Lot Size PM i Owner's Nam Address f 4Phone f Contractor .WAe i Address � , zq _ License No Phondo_: TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ —FOUND_ATION.-- .AGRICULTURE,WELL. _ __OTRi W HEELL PITS/SUMPS INTENDED USE__ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind I ❑ Open Bottom Cl Ma�Seca Dia. of Well Excavation Dia. of Well Casing C�7 D/.mestic/Private F-1 Gravel Pack racy Type of Casing Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation --Approx. Depth I i Eastern ace I tailed by _ Repair Work Done ❑ Type of Punip H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material (below 501 TYPE= OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if-public sewer is available within 200 feet.)., S 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance jto nearest: Well Foundation Property Line d LEACHING LINE ❑ No- & Length of lines Total length/size 1 FILTER BED ❑ Distance;to nearest: Well Foundation _ Property Line SEEPAGE PITS 1. 1 Depth j Size Number e w;�.SuMPS T -_.� L1 Distance io nearest Well Foundation Property Line DISPOSAL PONDS ❑ 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 on reverse side. Signed X_ ��eZ Title: Date:/ FOR DEPARTMENT USE ONLY Application Accepted by / ' Date y� a� Area or Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: El 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, is FEE AMOUNT DUE ' AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT NO. ♦.EH 13-24(REV.1/M5) _ EH 14-26 gel o