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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZE I ON AVE., STOCKTON, CA it Telephone (209) 466-6781 �! PERMIT EXPIRES 7 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 i / nstall the e work herein described. made in compliance bed. This application is p ce wrth San Joaquin County Ordinance No.549 for sewage or No. 1861 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District. + Job Address - City Lot Size "pM i Owner's Name i dd ` Phone Contractor dress , icense No. Phone TYPE OF WEL /PUM 4 2, ��Z NEW WELL ❑ 44 WELL REPLACEMENT ❑ DESTRUCTION t Y k 1 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel_ Pack ❑ Trac � »--...` V Type of Casin ❑ Public h � g Specifications ❑ Other t i a ' Depth of Grout Seal I Type of Grout .: ❑ Irrigation Ap epth ❑ Eastern — I` ; , Surface Seal Installed by # {r Repair Work Done ` �– pek of Pump H.P. `R "r State Work:Done Well Des n ❑ Well Diameter ttt Sealing Material.(top 50') DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NEWINSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Y 1 p -�.� available within 200 feet.) Installation will serve: Residence L[� Commercial Other 'Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a. � - `Water table depth SEPTIC TANK El Type/Mfg m Capacity I No. Compartments PKG. TREATMENT PLT. ❑ y < Method of Disposal i f Distance to nearest: Well0.QFoundation _ Property Line 11 .% ! LEACHING LINE A No. & Length of lines ' --.�. I r ' Total length/size FILTER BED ❑ Dtistance to nearest: Well Foundation property Line Ei .t cii SEEPAGE PITS ❑ D_epth _f - _Size Number ' CEO% Distance to'nearest: Well Foundation Property Line „ L PONDS I herebycertify that I have re pp + #y prepared this application Health and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sar1-Joaquin Local Health District, v t 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 certify that in the performance of the work for which this tion laws of California." 14 permit is issued,I shall employ persons subject to workman's compensa- , t: f The applicant ryWst c all required in ons. Complete dr'wing'on-reverse side. Signed Title: ' Date: s FOR DEPARTMENT USE ONLY j Application Accepted by rn 4 J Date *Area VPit or Grout Inspection by I. Date2_ [ Final Inspection by/ Date Additional Comments: �b �}-1y�K { ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ T acy 835-63E3.5. f Applicant- Return all opie to. Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � p FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE TERIT"N0. ,,jf - + EH 1124fREV.i/B51 �_7 L1 f '�7 _ 1d 7 y,/J EH 1428 !r ��I !.+ r t C /(./7 IJ' i "' �