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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED rL hc 1 rr.ln (Complete in Triplicate)Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installthe work 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. City Lot Size PM Job Address f�f Poon ` Owner's Name Address *' Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI N ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR LL OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL Pfl08 MAR CONSTRUCTION SPECIFICATIONS f ❑ Industrial 11 Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private LI Gravel Pack racy Type of Casing_ asing Specifications I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' I I Irrigation —.Appr epth 1 1 Eastern Surface Seal installed by - Repair Work Done ❑ Type ump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Ma rial (top 50'1 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION [.'I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is f available within 200 feet.) ` Installation will serve:. Residence_ Commercial— Other n Number of living units: Number of bedrooms tfA Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK _ -❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ r Method of Disposal i . Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest• Well Foundation Property Line DISPOSAL PONDS ❑ , 1 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 f 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." 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 applican u call for al fired ' coons. Comple drawing on reverse side. Signed X Title: Date f�— FOR DEPARTMENT USE ONLYY. Application Accepted by — �2 _. Date Area Pit or Grout Inspection by ' Date - Final Inspection by Pate Additional Comments: ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r .. 3 r FEE AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT'NO. INFO -� Q � � �� t3-24 1FiEV.1/K 51 i 0 ,T, �� EH 14.21