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i APPLICATION FOR PERMIT 5 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 Lot Size PM _ Owner's Name � .SJ � /�Cf�/I`�Address _ Phone -/ k. or Contractor&I Address a Lir ya License No. / Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PRQ� 6lAhE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industria) ❑ Open Bottom ❑"Mant – --Dia. of.-Well Excavation–– �< --• Dia. of Well Casing y {❑ Domestic/Private ❑ Gravel Pack' racy Type of Casing Specifications f 1 Public r Other '' ❑ Delta Depth of Grout Seal Type of Grout S I I Irrigation pprox. Depth I 1 Eastern Surface Seal Installed by r' F Repair Work Done Type of Pump H.P. State Work Done _ I; Well Destr ' n ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 [ TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION LI DESTRUC71O No septic system permitted if public sewer is i I available within 200 feet.) t Installation will serve: Residence- Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: YT~ W Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENTTPLT. ❑ Method of Disposal V Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line SEEPAGE PITS I I Depth I Size Number 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 i rules and regulations of the San Joaquin Local Health District, I 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."Contractors 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." The applicanyTus, call for all required i pe ions Complete drawing on re e " Signed X Title: Date: k., t. FOR DEPARTMENT USE ONLY r � 1 i Application Acceptedby Date Area i -7 # Pit or"Grout Inspection by = Date 1 �nspecpon.by Dateitional Comments: Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 l plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT D AMOUNT REMITTED CASH RECEIVED BY DATE PEERRMIT*NOO. ` + EH 13-24 IREV.1/K 51 F EH 14-28 • f