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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /J av 6 I . 7-4A 1� { Job Address City Lot Size PM LCo ner's Name0 p 1��_�tJ !J�A)Address Phone , nlraciot4!+]/U1U/d Address Q License No. Phone77 - � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL XMAREANSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack e of Casing Specifications Public F1 Other th of Grout Seal Type of Grout i I Irrigation _.Apprpx. Depthface Seal Installed byRepair Work Done ❑ Type of Pump State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 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 CA 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 LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."Contractors(tiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The appl) must call forII required inspections. Complete drawing an reverse side. Signed X Title: C t lyMb.' ,. _ Date: FQR DEPARTMENT USE ONLY Application Accepted by Date '� ~ Area Pit or Grout Inspection by Date Fii I Insp ction by �D�atta Additional Comments: r� G IC ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71134 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 10 INFO FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT-NO. + EH 1344 1REV.ti+s] � EH 14 I f i 48