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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i + 1601 E. HAZE T ON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 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. {� 33 L M S / i Job Address City . a Lot Size PM Owner's Name �.� Address /atQ Phone Contractor Address 2iS � "L' ,e No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q I N , DISTANCE TO NEAREST: SEPTIC TANK /OZ2 " SEWER LINES DISPOSAL FLD. Ze tPROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION§ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /f Dia. of Well Casing X Domestic/Private XGavel Pack Tracy Type of Casing Pif0 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .5-6 ;Type of ut ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by e Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other µ { 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 ppg PKG. TREATMENT PLT. ❑ Method of Disposai1 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 ❑ Depth Size Number ra 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 Local Health District. Home owner or licensed agent`§,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 4 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 Calif rnia." The applic n st call for all required ' ctions. Co plate drawing on r arse sMe. Signed Title: OR DEPARTMEN ONLY _Application Accepted byS , Date res Pit or Grout Inspection by Date Final Inspection by Foate-„- — —— pbVV# 1 1— _ -gS W_ r Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 8<35-6= Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C�1 FEE AMOUNT DUE AMOUNT REMITTED CSR RECEIVED BY DATE PERMIT NO. INFO rxP (}� + EH 13-24(REv.s/85) �i,}— 00 0114-26