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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209? 466-6781 PERMIT EXPIRES 9 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 i6stail 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 i Local Health District. Job Address C;,ty. Lot Size QPM /� Address Phone J 4 Owner's Name / r ePha ContractAddre9 /w LicensZ a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F] 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 PROBLEM AREA CONSTR ATIONS ; ❑ Industrial ❑ Open Bottom ❑ Mantec ia. of Well Excavation Dia. of"Well Casing r ❑ Domestic-/Private ❑ Gravel Pack racy Type of Casing .Specifications Fl Public n Oth ❑ Delta Depth of Grout Seal wY Type of Grout-.--. 1 1 Irrigation V " --Approx. Depth I:I Eastern Surface Seal Installed by Repair Work ❑g `tType of Pump H.P. State Work Done Wel ruction ❑, Well Diameter `ti,, Sealing Material (top 501 _ Depth 's Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I 'REPAIR/ADDITION I i DESTRUCTIO (No septic system permitted if public sewer is . � - available within 200 feet.) Installation will serve: Residence Commercial Othr r' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest:! Well Foundation Prioperty Line I LEACHING LINE ❑ No. & Length of lines f y ;`' ' Total length/size FILTER BED ❑ Distance to nearest:; Well # Foundation Property'Line 4 SEEPAGE PITS ( I Depth Size .Number.` SUMPS L-I Distance to nearest:- Well Foundation Property Line DISPOSAL PONDS ❑ t t 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 ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subje 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." Y The applican ust call for all requirgo inspections.-Complete drawing on rse - Signe Title: Date: FOR DEPARTMENT USE ONLY VkN' 4s y * Date 2Z `' NArea Application Accept d by• 4� Pit'or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 - ILI Manteca -7144" EJ Trac 835- I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., A 95241 Ne FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO171 CASH +.EH 1324[REV.r/H 5] EH 14-26