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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 i ;PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) application is 3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District, p ray I-:.. 1 ¢� PM IS: q I.L City f'tJ tot Size Job Address 7 f f [i L. Address tr — - Phon� Owner's,Name + 1 Y 1 f License No. Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { .} ->' `'I DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST, _TIC TANK r SEWER LINES Z - PITS/SUMPS FOUNDA AGRICULTURE WELL ' + INTENDED USE TYPE OF WELL EM AREA RUCTION SPECIFICATIONS N Dia. of Well Casing 'El Industrial R ❑ Open Bottom ❑ ca Dia. of Well Excavation specifications 3❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Typ asing Type of Grout M Public D r <1 Delta Depth of Grou i i I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by 1 ` Repair Work none, ❑ - H P State Work .Type of Pump y .T , i Well Destruction El Well Diameter Sealing Material Stop 501 { Depth Filler Material {Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I ! DESTRUCTION avlailablerw thin 200 feetosec systemrt�ed if public sewer is I r Y r Installation will serve: Residence X- Commercial_ Other F c t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 I Distance to nearest: Well Foundation, Property Line LEACHING LINE ❑ No. & Length'of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation ' ' Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest-`- Well Foundation Property Line 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 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 whic}this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Title: Data: Signe[! X . ��I��ORDEIP�AlTMENT USE ONLY Application Accepted by Date Area i pate Final Inspection by Data Pit or Grout Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton-Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT' O. INFO - GASH H r.EH 13-24 IREV,I/rs sl €H 1428