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- - r APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 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/of 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 1 Local Health District. Job Address `' z D � _ - City J Lot Size PM Owner's Name �' Address r Phone Contractor L� Address License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ma eta Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packl ❑ cy Type of Casing Specifications (`l Public Il Other ❑ Del Depth of Grout Seat Type of Grout I I Irrigation pprox. Depth I I Easter Surface Seal Installed by Repair Work Done ❑ ype of Pump H. State Work Done Well Destruction � ❑ s Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF-SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTIOI (No septic system permitted if public sewer is available within 200 feet.) [n Installation will serve: Residence_, Commercial_ Other V t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Typ'/ few' rt aci No. Compartments PKG. TREATMENT PLT. ❑ ;,. E Method of 6isposal U Distance-toynearest: Well Foundation Property Line ermit may .have expired without LEACHING LINE ❑ No. &N t l pre " %J1__r W)JWGt Total length/size FILTER BED ❑ Distance t trg Wel4 { }�"" "� F undation Property line lJ�LlfWbnrnF caMP,-aP Moon SEEPAGE PITS fl Depth Size Number SUMPS Ul Distance to nearest: ,Well Foundation Property Line DISPOSAL PONDS ❑ t G 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 District. 5 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 signatures 1 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 componsa-X tion laws of California." The applicant st call for all required inspections. Complete drawing on reverse side. Signed X '/ Titre: w _ Date: FOR DEPARTMENT USE ONLY �] Q� Application Accepted by —l� l�1 Date ` -'ZiZ A— � Area C-1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ��- _1 Y�1"k" ❑ 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 I OK RECEIVED BY DATE PERMIT-NO. INFO GASH +.EH 13-24{REV.r/m!5) - EH 14-26 ff