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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 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 incompliance 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 of Size �^ l r O PM Owner's Na Address y —4 Phone Contractor Address License NO. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAR PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL LEM-AREA____CONSTRUCTION SP_ECIFICATIO ❑ Industrial D Open Bottom ❑ lye a xcavation Dia. of Well Casing ❑ Domestic/Private c D Tracy a of Casing ) Specifications FI 1 Publi ❑ Other ❑ Delta Depth out Seal �II_ .., Type of Grout rrigation -Approx, Depth i I Eastern 'Surface Seal Ins by t Repair ne ❑ Type of Pump H,P. Sta I rk Done._ 1 Well Destruction ❑ Well Diameter # Sealing Material Itop 50'1 Depth Filler Material (Below 501 `; I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I 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 i Character of soil to a depth of 3 feet: — — f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments P PKG. TREATMENT PLT. ❑ � Method of Disposal Proper Distance to nearest: Well Foundation ty Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth 11 q Sire Number f SUMPS 0 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 i 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 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 mug call for all required spedtio s. Cymplete drawing on reverse side. Signed Title: _ 6l C1"7Z /, t-,- Date: 4-,1-1,2 FOR DEPARTMENT USE ONLY Application Accepted by Cr`--�J Date Area Pit or Grout Inspection Date Final Inspection by s ate Additional Comments: 3 ; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 tNFO �jr�. CAS RECEIVED BY DATE PERM17'NO. +,EH 14-24(REV.t i x 5) 1 EH 14-28 C/�