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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Q � .• Telephone {209) 466-6781 ��o PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / (Complete in Triplicate) Application is heieby 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. 1 ll'} Job Add res –1 City t Size ��r `I/ PM a Owner's Name —_- Address Phone �J Contractor 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 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications ,y ❑ Public ❑ Other F] D Depth of Grout Seal Type of Grout ❑ Irrigation Approx. LJEastern Surface Seal Installed by Repair Work Done EDT ump H,P. State Work Done Well Destruction Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 /1 Character of foil 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 ❑ Depth Size Number SUMPS ❑ 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: '9 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 must all for all uired inspection Complete drawing on reverse side. ��cc'� �J igned X Tit(e: �/� Dat'a — ` FOR DEPARTMENT USE ONLY r Application Accepted by Date r� Area Pit or Grout Inspection by Date Final Inspection by4JAZ41� Date Additional Comments:ZL�11_11� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma 823-7104 ❑ Tracy 835-63B5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O., Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED C K RECEIVED BY' DATE PFRMIT'NO. + EH1321(REV.i/as) oZ �" •�,� o aS �' I +� L.. -2 EH 1429 ✓J ..7C� i