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j ,.. APPLICATION FOR PERMIT �[ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (208) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED .J. (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 weii/pump and the Rules and Regulations of the San.Joaquin Local Health District.' ' Job Addre"ss City "� y Lot Size PM Owner's Name n( - r— Address Phone Contractor A Address TYPE OF 1NELL/PUMP: NEW WELL LJ PUMP License No.� Phone WELL License T ❑ DESTRUCTION 1-1INSTAL TION EI R AIR ❑ ' DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ . SEWER LINES DISPOSAL FLD. � FOUNDATION AGRICULTURE L PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL P_OBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ nteca Dia. Of Well Excavation 171Domestic/Private ❑ Gravel Pack 11Trac Dia. of Wel! Casing .1 l'1 Public TYPe of Casing M Other ❑ Delta Depth of Grout Seal Specifications I 1 Irrigation —.Approx. Depth 11 Ea emTYPe of Grout Repair Work Done D Type of Pump Surface Seal Installed by H.P. - Well Destruction State Work Done ❑ Well Diameter Sealing M erial (top 50'1 a Depth Filler Materia (Below 501) TYPE OF SEPTIC WORK; -NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION [No septic system permitted if public sewer is Installation will serve: ResidenceCommercial Other available within 200 feet.) 4 + _ ` n Number of living units: Number of bedrooms V{ Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth ��_ �^ PKG. TREATMENT PLT. ❑ Capacity__ No. Compartments Distance to nearest: WellMethod of Disposal (�, Foundation Property Line l/ LEACHING LINE ❑ No. & Length of.lines T FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line rn SEEPAGE PITS C I Depth Size SUMPS Number T— ❑ Distance to nearest: Well Foundation � DISPOSAL PONDS ❑ Property Line 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, and0 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 notr 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 ,a. The appli nt must call for a r ui Inspe ions mplete drawing on reverse side. ` Signed _ P /x Title: Date" p OR DEPARTMENT USE ONLY 14 Application Accepted by 3� 2 Data Area ' Pit or Grout Inspection Date Final Inspection by Date . Additional Comments: ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton e., P.O. Box 2009 k., A 95201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVED BY f CASH DATE jPERMIVNO f# + EH 13.24 JAEV"i/e 51 EH 14-26 ��` "/2 J