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- . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STO.CKTON, CA d "'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (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 a +�Q I J Citof Size y T PM ��[- + Owner's Na PZ0 Address Phone Z IM Contractor I Address License No. Phone_ TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE- FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE' OF WELL PROBLEM AREA RUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation pprox. Depth 7 ❑ Eastern Surface Seal Installed by i Repair Work Don Type of Pump H,P. State Work Done_ V Wefl D tion ❑ Well Dliameter Sealing Material Itop 50') t Depth�M Filler Material (Below 501 wd TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION,,V {No septic system permitted if public sewer is � TM`- --- -available within 200 feet.) Installation will serve: Residence—' Commercial_ Other 1 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. ❑ I�" f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ NJ& Lang th'of lines Total length/size FILTER BED ❑ Distance to nearest: - Well Foundation Property Line E SEEPAGE PITS ❑ . Depth ; Size A Number SUMPS, El 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 mannei Contractor's hiring to become subject to workman's compensation laws of California." Contractor' 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 Ca' rnia." i - The ap n st call for atl required inspections. Complete drawing o everse side. Signed Title: Date: ' FOR DEPARTMENT USE ONLY t Application Accepted by Date — Y�Area I' 60 Pit or Grout Inspection by Date Final Inspection by Date J� 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 FEE INFO AMOUNT DUE AMOUNT"'REMITTED {{ CK t RECEIVED 6Y DATE �PERMIT�N0. '+ EEH 73-24 H 14-28(REV.I K51ll IP 0c) �.1 1 i--' ' ' f: