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II :4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA C Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Applicatijon 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. If Job Address t City of Size PM XOwner's Nameddress y��/fJ l S � Phone — � -�i �. Contractor �I Address License No. Phone TYPE OF WELL/PUMP: ib NEW WELL ❑ WELL REPLACEMENT ❑ IJESTRUCTI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THE ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DIS 51L ELD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack••--v� racy -•- - Type of Casing Specifications ll Public ❑ Other l-1 Delta Depth of Grout Seal Type of Grout a I I Irrigation ry rax. Depth �1 l Eastern Surface Seal installed by { Repair Work Done ❑ pe of Pump - H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material {geiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION i,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 X.Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L10. ryt Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i _ y . FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 13epth! Size ? Number I SUMPS 0 Distance to-nearest: Well f Foundation Property Line DISPOSAL PONDS ❑ ii i 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 I 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu tall or all required in -t ns. Co lete drawing on reverse side. j Signed X ti t Title: Date: U s yl. FOR DEPARTMENT USE ONLY ry �'j Application Accepted by �C - Date L rO` r Area a 42, Pit or Grout Inspection bate Final Inspection b Date 7✓ /•�� Additional Comments: 6 LlStk 466-6791 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63i5- Applicant.- Return all copies to:. Environmen;al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. F + EH 13-21(REV.t � EH 11-28 � �i. o � '