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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. Q s z City Lot Size PM Job Address P Sa�7 Phone Owner's Name Address p yZ /� � Phone Contractor � Address License No, TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT" LJDESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION "'.AGRICULTURE WELL' ' O ELL tPITSISUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS El Industrial El Open Bottom [IManteca Oia ell Excavation Dia. of Well Casing ❑ DomesticlPtivate ❑ Gravel Pack ❑ Tracy ype-of Casing Specifications >� f l Public f} Other Cl De depth of Grout Seal Type of Grout n„ I I Irrigation �..Approx. Dept Eastern Surface Seal Installed by - `+\� Repair Work Done L] Type of Pu H.P. State Work Done ". C Well Destruction ❑ Well Diameter Sealing_ g Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION [ I DESTRUCTIO (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence — Commercial_ Other Number of'Iliving units: Number of bedrooms f Character of'-soil to a depth of 3 feet: C- Water table depth SEPTIC TANK ! Type/Mfg Capacity No. Compartments PKG. TREATMENTYLT❑ „, Method of Disposal —Distance to nearest: Well . ,Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation. Property Line F SEEPAGE PITS I'I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line i 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 st call for all require inspections. Complete drawing on reverse side. Date: JSigned X - `" Title: ~•� �""� FOR DEPARTMENT USE ONLY r Application Accepted b Date 3-� Area f Pit or Grout Inspection by _ Date. Final Inspection by ate Additional Comments: U ~ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me eca 823-7104 ❑ Tracy 535-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. -•y/, + EH 13INFO 24(REV.1/857 I EH 14-29 ,