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/ lamr� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Nv %wa%- U, 1601 E. HAZELTON 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. Job Address City Lot Size PM Owner's Name Address �d Phone ILI— Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU AI-{D PUMP IN CATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom w anteca . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type o sing Specifications ❑ Public ❑ Oth ❑ Delta Depth of Grou al Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed Repair Work Don Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 W TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ( No septic system permitted if public sewer is available within 200 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 ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 9 LEACHING LINE ❑ No. & Length of lines w Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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. 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 hiringOT 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 Iicant must all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: F RTMENT USE ONLY Application Accepted by 1+�. Date ��ar,��--C62 Area tD_ ,— y Pit or Grout Inspectionby p Date Final Inspection by_`- , l�/L� DateZ>.*D Additional Comments a"4'�-^�` �-� / ! ❑ Stk 466-6781 ❑ Lodi 369-3621 &nt.,, 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EHt3-24 IREV.t i n s) i V C7 EH 14-28 `+r"' �Jco 0