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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 d Regulations of the San Joaquin Local Health District. s L Job Address LIM- City Lot ize PM Ow errs Name AddressJE t ' Phone Contra orN 1ZP44*"t' Address icen No. rib Phone TYPE OF ELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO EAREST: SEPTIC TANK SEWER LINES DI OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS _ INTENDED USE TYPE OF WEV REA CO STRUCTION S ECIFICATIONS Industrial El❑ Open Bottea. of Well Exca tion ir Dia. of Well Casing ❑ Domestic/Private Gravel PackType of Casing SSpecifications❑ Public I� therDepth of Gro Sealy T pe of GroutI i Irrigation prox. Surface Sea Installed byRepair Work Done ❑ lype f mpP- State Work DoneWell Destruction ❑ sWell aaling'Materiaf (t `50'1Deptler Material {6e w 50'} TYPE OF S TI WORK: `VVINSTALLA O 1 1 REPAIRIADDITION I DESTRUCTION i I (No septic system permitted if public sewer is „ available within 200 feet.) Installati n will serve: sldence_ C m ial_ Other r Number f Iiv' g it - _ Numbe of bedroo s ; Characte of oil a depth of 3 feet-, Water table depth O I SEPTIC TA K ❑ Type/ g Capacity No Compartments PKG. TREA T PLT. ❑ Method of Disposal 3 D tante to nearest: Well Foundation Property Line t a � LEACHING LINE No. fig Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well undation Property Line SEEPAGE PITS 11 Depth S' a _ Number V ' I SUMPS LJ Distance to nearest: ell Foundati Property Line a DISPOSAL PONDS 1 F1 1 hereby certify that I have prepared this application nd that the work will be done in ac rdance with San Joaquin county ordinances, state laws, an t rules and regulations of the San Joaquin Local Hea h District. Home own or licensed'agent's signature certifies he following: "I certify that in the performa a of the work for which this permit is issued, I shall no employ an p rson in such manner as to become ubject to workman's compensation laws of Cali nia."Contractor's hiring or sub contracting signator$" certifies t f lowing: "I'ce ify that i the pe r ante of the work for which this permit is issued, 1 s I employ persons subject to workman's compensa- tion laws f lifornia. The applica ust all ora re u i t pe ons. Complete drawing on ve de Signed X Title: Q_ �j Date: FOR DEPARTMENT USE ONLY t Application Accepted by v Date rea µPit or Grout Inspection by y la - +> > r Date . 'Final Inspection by v Date 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 I FEE AMOUNT DUE AMOUNTREMITTED CK INFO CASH RECEIVED 8Y DATE PERMIT'NO. ♦.EH 13-24 IREv. /n 51 lvr AEH 14-28 `!