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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address 3Y e City Lot Size �b V Z� n PM Owner's Name ddress Phone qV12707 / IF Confracfordress" - �' ° License,No Phone S�Z �. TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE' FOUNDATION Xn ;aap WELL %-OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBSTRUCT[ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trae of Casing Specifications M Public ❑ Other 71 Deth ofGrout Seal Type of Grout I1 Irrigation _Approx. Depth l I Easrface Seal Installed byRepair Work Done ❑ Type of Pump State Work Done WeH Destruction ❑ Well Diameter r"I )top 501'' Depth Filler Material (8el ') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION V1 DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Y_ `Other Number of living units: Number of bedrooms Iy(�U'"t_ • Character of soil to a depth of 3 feet: In Water table depth SEPTIC TANK ❑ Type/Mfg tj JCapacity No.'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal-, Distance to nearest: Well V Foundation Property Line LEACHING LINE ❑ No. & Length of lines IT, YO hq Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE; PITS I I Depth size Number a SUMPS ❑ Distance to neares : Well Foundation Property Line r DISPOSAL PONDS 0 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'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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ^^ ' k The applican must tail fo 11 require inspections. Complete drawing on reverse side. , Signed Title: Date:�~ y FOR DEPARTMENT USE ONLY Application Accepted by Date � Area 1 f Pit or Grout Inspection by - Date Final Inspection by Date Additional Comments: �+�D f – ❑ Stk 466-6781 todl i 369-3621 Manteca 823-7104 ❑ Tracy 835-&385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 REE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMET NO. INFO �} CASH +.EH t3-24IPEV.rinsr 7 0 fl 7 0 O C� �� EH 14-ZB