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I � Q APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE-, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.welUpump and the Rules and Regulations of the San Joaquin Local Health District. XJob Address City- Q Lot Size PM ' �--� Phone `! Owner's Name Address Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q/ DESTRUCTION ❑ \ PUMP INSTALLATI N ❑ SYSTEM REP #fi 0 OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU5E4ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION SPECIFICATIONS [� ❑ Industrial ❑ Open Bottom .-❑ Ma ca. Dia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private ❑ Gravel Pack racy' Type of Casing Specifications 1`1 Public ❑ Other 1 Cl Delta De of Grout Seal Type of Grout I I Irrigation —.-Approx. epth I 1 Eastern Surface al Installed by C\ Repair Work Done ❑ Type of Pump k H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 _ (� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I (No septic system permitted it public sewer is 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 ❑ TypelMf9 iCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance;to nearest: Well ,Foundation - Property Line a LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line ;I SEEPAGE PITS 11 Depth j Size _ Number SUMPS ❑ Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di$trict- 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 this permit is issued, 1 shall employ persons subject to workman's compensa- lion laws of Calif rnia." The applicant mu call for aalll required inspection Complete drawing on reverse side. J�Signed X Title-:—. Date: Q�� e FOR DEPARTMENT USE ONLY Application Accepted by y U` Date "��Are,, Pit or Grout Inspection by t Dat Final Inspection by — Date—� Additional Comments: 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 Ll Manteca 623-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k INFO AMOUNT DUE AMOUNT REMITTED //y�C.,ASH RECEIVED BY (`�—D�A-TJ'E' PERRMIT/'NOO..) +.EH 13-24(REV.t i h 51 } V�� ! { �. ! C.J [ �/} - EH 14-28 (/l _V ClU y//