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w 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 install the work herein 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. II'' f Job Address T (/Jt�O/ City I Lot Size 1!^� PM Owner's Name 17— LAddress 3 L�+ Phone 7 2 I Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK µ SEWER LINES x DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER W S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON N SPECIFICATIONS,N © Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout---. l I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Do Type of Pump H.P. State Work Done Well D ction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIRlADDITION ( I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms f Character of soil to a d th of 3 feet: Water table-depth SEPTIC TANK Type/Mfg F Capacity No. Compartments l PKG. TREATMENT PLT. ❑ Method of Disposal J ; Distance to nearest: Well Foundation Property Line:,._.. i LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, an 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 Ply 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." T licant must or all t ired s!C"- S. rawing on reverse side. Signed X Title: Date: 6 OR DEPARTMENT USE ONLY IFIVApplication Accepted byMADate L y� ~�� Area +� Pit or Grout Inspection Date Q p Final Inspection by Date Additional Comments: 0 Stk 466-6781 © Lodi 369-3621 ❑ Manteca 104 © Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO, INFO EH 1324 I REV.I/n 51 U C) V C� EH 14-26 „j� X31 ll