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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i Application is.heieby 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 i Local Health District. Job Addres� Ci Lot Size PM Owner's Na "-.1 6 &_ Address Phone Contracta " Addres License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WEL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca N . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications 1-1 Public H Other ❑ Delta Depth of Grout Seal Type of Grout —.— I I Irrigation prox, Depth I I Eastern Surface Seal Installed by _. Repair Work Dane ype of.Pump H.P. State Work Done Well Destruc' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYft OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION l 1 DESTRUCTION No septic system permitted if public sewer is v a vailable within 200 feet.) Installation will serve: Residence�____ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 L7 Distance to nearest.: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that!.have prepared this application and thatr 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 f 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 applicant ust call for all required inspections. Complete drawing on rev side- �- Signed X - Title: chi Date: y FOR DEPARTMENT USE ONLY Application Accepted bye Date Area Pit or Grout Inspection by #7 Date Final Inspection by , Date c Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Anteca 623-7104 ❑ Tracy 835-6335 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 CK RECEIVED BY D TE PERMiT�NO. INFO CASH i + EH 13-21(REV.i i rs 5Y 76 �,�`� �� -7 �0 I EH 11-29 �/C 444ii� cf F D r� 3