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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE`T ON AVE., STOCKTON, CA Telephone (206) 466-6781 PERMIT EXPIRES 1 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 a made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatiorts of the Srcan Jat7on is Local Health District. Joaquin Job Address r City Lot Size—_. PM ! Owner's Name Address S'6 ^Z .one f I `'= � Contractor Address Ph TYPE OF WELL/PUMP: License No._Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP NSTALLATION ❑ SYSTEM REPAIR t,I ' DISTANCE TO NEAREST: SEPTIC TANK OTHEA ❑ r -SEWER LiNES .DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll { Industrial ❑ Open Bottom ❑ Man � �im Dia, of Well Excavation ,v ❑ Domestic/Private 1:1 Gravel Typo of Casin Gravel Pack Dia. of Well Casing g v� } Specifications E) Public El Other ❑ Delta Depth of Grout Seal F1Irrigation --Approx. Depth El Eastern Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Well Destruction El Well Work Done Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is Installation will serve: Residence— CommercialOther available within 200 feet.) + Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` SEPTIC TANK ❑ Type/Mfg F Water table depth PKG. TREATMENT PLT. [ICapacityNo. Compartments I i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines j i i Total length/size FILTER BED ❑ Distance to nearest:..Well Foundation Property Line SEEPAGE PITS ❑ Depthi p Size Number ' SUMPS El Distance to nearest: Well DISPOSAL PONDS r-1FoundationProperty Line 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."Contractors 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 must,-call f all requ' d inspections. Complete drawing on reverse side. I Signed itle: - Date: F EPARTMENT USE ONLY f Q G , Application ccepted b Date `"Q Area 19A ��^, f Pit or Grout Inspection b �` �J Date Additional Comments: Final Inspection by r �r Date ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-OW Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED INFO C RECEIVED BY ED) TE PERMIT'NO. + EH 13-28/REV.I/a sI * EH 7428 ` O !