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ti APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT NaWJ.Q� 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 ; . �n►On PERMIT EXPIRES TYEAR FROM DATE ISSUED Cr�Lbl V (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 Fr `7 City Lot Size PM Owner's Name ' ` Address _ phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r - PUMP INSTALLATION ❑ SYISTIEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS PROP. LINE ` FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS Q ❑ Industrial Cl Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel r ❑•Tracy Type of Casing Specifications f"1 Public er Cl Delta Depth of Grout Seal Type of Grout i. I 1 Irrigation �T—.. Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work a ,-❑ of Pump H.P. State Work Done_ f Well D ruction ❑ Well Diameter Sealing Material Itop 50'I �� } Depth Filler Material (Below 50') I i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l l DESTRUCTION ,(No septic system permitted if public sewer is t 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. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size � I FILTER BED ❑ Distance to nearest: Well Foundation Property Line .4 SEEPAGE PITS I I Depth } Size Number r SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature k 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." � Iicant mus I f�alluird inspections. Complete drawing on reverse side.. - Signed X Title: Date: FO EPARTMENT USE ONLY Application Accepted by �� . s0_r.r�ry� /� Date Area 1.1D Pit or Grout Inspection b Date Final Inspection by Date! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 1 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviro ental HealthiPermit/Servic 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA-95261 � � s a FEE AMOUNT DUE AMOUNT REMITTED -CASTrCK RECEIVED BY PATE PERMIT N0. INFO ♦ EH 13-241REV.ti/x51 �d� EH 14-26 i s i