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4 E -- (fAPPLICATION,FOR PERMIT SAN JOAQUIN LOCAL H H DISTRICTv wc�_ 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone {209} 466-6781 f' 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. i ` Job Address City' Lot Size PM Owner's Name raAAddress + Phone Contractor, Address License No. -�W Phone 0% f TYPE OF VVELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ ITANCEPt(t�NEAREST: SEPTIC K SEWER LINES DISP05 PROP. LINE FOUNDATION, AGRICULTURE WELL ER WELL PITS/SUMPS ,INTENDED USE TYPE OF WELL P Ea-AREA CO CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr a a of Casing Specifications F] Public ❑ Other it Dept Grout Seal Type of Grout t 1.3 Irrigation ---Approx. ❑ Eastern Surface Sea alled by Repair Work Done ❑ Type o mp H:P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 50') Depth Filler Material {Below 501 I TY E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is 4 available within 200 feet.) Iristallation will serve: Residence_ Commercial_ Other number of living units: Number of bedrooms Character of soil to a depth,of 3 feet: Water bte depth SEPTIC TANK ❑ Type/Mfg .. Capacity No. Compartments ,�r_PK'G. mpartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEA�rCHING LINE EJNo. & Length of lines i Total length/size ��yy FILER BED ❑ Distance to nearest: Well Foundation Prope L`itTe SEEPAGE PITS ❑' 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 Wcaf-Health DistricO: 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 k emp)oy any person in such manner as to belpome subject to workman's compensation laws ofCalifornia." 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 ""'' P p y persons subject to warns compensa- tion laws of California." T icant mus"J for all required in cti s. Cbmplete drawing on reverse side. Id i9n�d Title: �ja ?r".��y �"1lR`. FOR DEPARTMENT USE ONLY { Application Accepted by G Dat 7 Area O3 Pit on Grout Inspection by f Date Final fnspactio 6 D to Addi'inal Comments: 1 ❑ A 466-6781 ❑ Lodi 369-3621� ❑ Manteca 823-7104 171 Tracy 835-k385 '+..�•^*_ -� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aver+, P.O. Box 2009, Stk., CA 95201 i FEE F INFO AMOUNT DUE,. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. l „+ EH 13-241REV.1iH57 �Uv i EH 1426