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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Locat Health District. Job Address �-� Cit Lot Size PM 1 Owner's Name Address Phone Contractorl Address -a"License N8` Phvn? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca - ia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private IDGPack ❑ ey"�r Type of Casing Specifications f'1 Public F] Other F] Delta Depth of Grout Seal Type of Grout I i Irrigation ox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ype of Pump H.P. State Work Done Well Destruct' CO3 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1 DESTRUCTIO No septic system permitted if public sewer is available within 200 feet.l 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Welt 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." Contractors 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 California." The appti a t must call for all require ins ctions. Complete drawing onre ase side, Signed Title: Date: 4 FOR DEPARTMENT USE ONLY Application Accepted by Date � o Area Pit or Grout Inspect' Date Final Inspection by Dates: Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ff DATE PERMIT-NO, t EH 1 -24 IRE:V.r/N 57 U'Q (:H 144-213 '�- 1 3 I�r iA11 I