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J� 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 t (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 ocai Health District. Job Address Isle ui ACity Lot Size PM p� � �/,., .�.,o Owner's Name jolva j Address �: =�" '` ��` Phone License No. Phone Contractor Address YPE OF WELL/PUMP: NEW WELL F1 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 PRO EM AREA�CONSTRUCTION SPECIFICATIONS Dia. of E71 Industrial ❑ Open Bottom ❑ Monte ,Well Excavation Dia. of Well Casing Type of Casing Specifications ❑ Domestic/Private LI Gravel Pack ❑ cY Type of Grout ('1 Public F1 Other ❑ Delta a th of Grout Seal I I Irrigation --Approx. pth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50) ^ Depth Filler Material IBeiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADD1T10N l 1 DESTRUCTIO I alvailabperw thin 20D feet.) if public sewer is _ 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. a 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 ❑ 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 s of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation law 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 must call foI required inspections. Complete drawing verse sidle. r I a 4AZ Si ned X Title: �V� � date: R DE RJA(I)=NT USE ONLY _ Applicati%Accepted by pate Area l Pit or Grout Inspection toFinal Inspection by Date / Additional CommenZts: "---�--.--..--� - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEMDUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INF f ♦ EH13-241REV.I/R51 3� r[JLl 3��. l EH 14-26