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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.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�.If(` �,, Job Address / L. I LA ,,( L( City L Lot Size _Ile 1C Q�/ PM Owner's Name _-_L- � #LQ ! , dress 7 3 1®/J Phone Contractor L� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA C�STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public ❑ Other Cl to Depth of Grout Seal Type of Grout _, I Irrigation _..App(ox. Depth l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material )top 50') ] Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is vailable within 200 feet.) I Installation will serve: Residence_X Commercial— Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal 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 I I Depth Size Number SUMPS Ll 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'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 applicant must call for all required inspec ions. Complete drawing on reverse side.slide. q �Signed X ? r e: W Date: I TT7 FOR DEPARTMENT USE ONLY ��/ Application Accepted by Date F r �+ Area �r Pit or Grout Inspect' n Date Final Inspection by 40V%2.9c Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERMIT NO. _T�S+ EH 13-24(REV.i/n 51 & �Z-1 (r ��