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APPLICATION FOR PERMIT J SAN JOAnUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209)466-678l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ? 0 (Complete in Triplicate) Application is hereby made to the San'Joequin Local Health District for a permit to construct and/or install the work herein described.This application is 4 made in comp6ence 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. Job Address �'! F C Loi Size PM � .. .l` �. , r.,. 1 .► 111+ '� �. .,.. D I .Phone r " Owner's Name —Address Contractor Address ZZLLicense No1 � Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE 1 FO TION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA RUCTION SPECIFICATIONS Industrial J ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing EJ Domestic/Private ❑ Gravel Pack ❑ Tr Casing Specifications , ❑ Public 111 Other Delta Depth.of Grou Type of Grout ❑ Irrigation ----Approz pth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Typ ump ' H.P. State Work Done Well Destruction ❑ e11 Diameter Sealing Material (top 50'1 Depth t Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is 1 I available within 200 feet.) Installation will serve: Residence_:_ Commercial_ Other Number of Irving 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. ❑ ( r i Method of Disposal ' Distance to nearest: Well Fouhdation Property Line-- - LEACHING LINE ❑ No. 11, Length of lines Total length/size— FILTER BED ❑ Distance to nearest: Well � Foundation Property Line J ( SEEPAGE PITS ❑ Depth ' Sae_ ' Number SUMPS O Distance to nearest: Well Foundation Property Line _ i DISPOSAL PONDS ❑ 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 fo all require inspections. Complete drawing on reverse side Signed Title: Date: �� FOR DEPARTMENT USE ONLY t Qn Application Accepted by Date _L o- v 1 Area .—Pit or Grout Inspection LY � ��Date__ Final Inspection by' Date Additional Comments: + W (->_;,°—'2v S ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823- 104 ❑ Tracy 835.8385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO f ♦ I:M13211REV. /Ah) -3S , EH 14-26 /