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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � ,� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 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. J PM abo�� U Job Address U City Lot Size - a Owner's Name U Address 1 U ° Phone T - 0 77 Contractor Address License No. Phone TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REP.AIR ❑ OTHE ❑_----- DISTANCE TON T: SEPTIC TANK SEWER LINES DISPO PROP. LINE FO f3A2jON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM ARfA STRUCTION SPECIFICATIONS ❑ Industrial _ ❑ Open Bottom ❑ Man Ilia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy f Type f C-asing Specifications I'1 Public t_1 Other ❑ Delta ; Depth of Grout Seak Type of Grout I € Irrigation pprox. Depth 11 EasternSuriace SSeal Installe`8'6y r Repair Work Done Type of Pump H.'P, State Work Done r Well Destruction 0 Well Diameter Sealing Material [top 501 Depth Filler Material 18elow 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION 1:1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other fUl + Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-1. 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 11 Depth Size Number SUMPS ❑ Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ 4 a 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,.1 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." Thea ica i m t call fo re i tions. complete drawing on reverse side. Signed Title: b7:%-4 Date: -7/,2 FOR DEPARTMENT USE ONLY Application Accepted by Date 'n-� h Area Pit or Grout Inspection by Date Final Inspection by Date � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 303621 ❑ Manteca 823-7104 doracy 836-6385 U 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 H RECEIVED BY DATE PERMIT'NO. + EH 13-2�1 (R EH EV.I/H s) ^-��0 429 S"