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q a r ;i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplete in Triplica#e) i 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. ` 'I Job Address L CityLot Size��' �� s PM Owner's Name I' v r A w+4 7 0� /g1_11 Address Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION ❑ PUMP INALLATION DI SYSTEM R IR ED] OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TAN SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM ARE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications :A 1'l Public n Other - Delta Depth of Grout Seal _ Type of Grout _ I I irrigation il-Approx. Dep 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamet r Sealing Ma rial (top 501 ° Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR)ADDITION l 1 DESTRUCTIONX (No septic system permitted if public sewer is r 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 PKG. TREATMENT PLT. ❑ �! Method of Disposal Distance to nearest: Well foundation Property line I n F LEACHING LINE ❑ No. & Length of lines Total length/size �y FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II r 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 DiMrict. 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, l shall not�gg employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 41 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." 0 1 '' The applicant st call for required inspe 'ons, Complete drawing on reverse side. Signed XZIA Title: Date: I� FOR DEPARTMENT USE ONLY rr Application Acceptedby ' r Date .c� Area Pit or Grout Inspection by ; Date F1 al Ins/pection by ' Date (� 1 S 4 T O —Purr, 7�v+� Additional Comments: I ,❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 �ti1n�P Applicant - Return all copies t!I: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT NO. INFO ryCASH t.EH13-241REV.ii851 EH 14-2e