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APPLICATION FOR PERMIT 1(0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. Job Address �rl Ajt City Lot Size PM Owner's Namew..�x4d.tY8 "lAtItIn Address l hone Contractor ".— ddress v l 7 icense No Y PhoneL Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYS REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:�SEPTIC TANK SEWER L E DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑/Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications f'l Public f1 Other 171 Depth of Grout Seal Type of Grout I I Irrigation _._Approx. Depth l I Surface Seal Installed byRepair Work Done f] Type of Pump . State Work Done Well Destruction ❑ WeM Diameter Sealing Material Itop 50') Depth Filler Material iBelow 50') # TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence bl-01 Commercial Other Number of living units: Number of bedrooms_ Character of soil to.a depth of 3 feet: 00 on Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ // �� Method D' Distance to nearest: Well Foundation zo Property Line V0 LEACHING LINE ❑ No. & Length of lines Zdk' Total ngth/size FILTER BED O Distance to nearest: Well Foundation Prop ine 1 SEEPAGE PITS I ) Depth _ ?_J Size NumberINZ SUMPS 1_-�LJ Distance to nearest: Well Foundation 9 Property Line DISPOSAL PONDS l ❑ S 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 Diltrict. f 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." r.r The applican ust call fog required spections. Complete drawing on reverse side. Signed X Title: , rr� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date —� Area t Pit or Grout Inspection by Date�a Final Inspection b Date?/ F I I Additional Comments: 1 LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 635-6385 ,t I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 3 CK 4 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY, DATE PERMIYNO. [ f.EH 13-24 IREV.t/)15) EH 14-29 / \� r�.