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0 APPLICATION FOR PERMIT L (� G— J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,;STOCKTON, CA 1i I� Telephone (209) 466-6781 � ` r � PERMIT I� EXPIRES"'I'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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.— "- � elf, Job Address City �� Lot Size PM Owner's Name I Address i i Phone Contractor Address ' ' A,Licenrse No. Phone TYPE OF WELL/P P: ill NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP1NSTALLATION ❑ SYSTEM REPAIR"❑"""""r""r'" OTHER ❑ ,P 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO AL ELD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS%SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom, WT Dia. of Well Excavation } Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr r Type of Casing Specifications 3 ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout Ll Irrigation �4,ppr epth ❑ Eastern Surface Sea] Installed by Repair Work Done ❑ T of Pump H.P. State Work Done ;1,. ' Well Destruction Well Diameter Sealing Material (top 50 f Depthl Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION fNo septic system permitted if public sewer is I ! available within 200 feet.) Installation will serve: Residence_ 'Com ercial_ Other Number of living units: Number of bedroom I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity PKG. TREATMENT PLT. ❑ ' -- . � No. Compartments , Dis� Method of Disposal tance to Barest: -Well Foundation Property Line LEACHING LINE' ❑ ' NA& Length of lines : Total length/size � FILTER BED ❑ Dis ance to nearest: Well Foundation +��property Line SEEPAGE PITS ❑ Depth tSize Number SUMPS ❑ Distance to nearest: Well'!�—Foundation— Property Line r DISPOSAL PONDS ❑ I . f I hereby certify that I have prepared this applicat'io'n an_d'–th;i-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: "I certify that in the performance of the work for which ithis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: . ... I _ _ Date: n FOR DEPARTMENT USE ONLY Application Accepted by �117rr1/�. Date c] Area (� ' Pit or Grout Inspectiont! Date Final Inspection by Dat�LJ! ! Additional Comments: I� ❑ Stk 466 fi7$1 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT.DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. + EH 13.24(riEV.1/95) - .EH,14-28• 1, .