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APPLICATION FOR PERMIT 4_tl i G L J t.,. c ! ,� h SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 n PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) h 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. ` IleJoh Address �`a Cit �tLot Size X'3G PM { Owner's Na . ' Address � /t' ` I d h Phone Contractor t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic;Private ❑ Gravel Pack ❑ Type of Casing Specifications Q 1`1 Public FI Other fl Delta Depth of Grout Seal Type of Grout _. I I Irrigation prox. Depth l I Eastern Surface Seal Installed by - Repair Work Done Type of Pump' H.P. State Work Done _ Well Dest n ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is } available within 200 feet.) Installation will serve: Residence_ Commercial-___ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to_nearest: Well Foundation Property Line SEEPAGE PITS i I Depth I Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ r 1 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, 1 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." i E The appl t must call flvr all required i spa n Complete drawing on reverse side. Signed [/// Title: jjake9'f Date: FOR DEPARTMENT USE ONLY /J Application Accepted byDate Area Pit or Grout Inspecti y_ Date Final Inspection by - Pate V/ ,�+ Additional Comments: 1 t A/, �- ot � + ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 / , ,„�•� 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE: AMOUNT REMITTED A H RECEIVED BY DATE PERMIT NO, INFO + Efl 4(REV.1/1457 EH 11-2 / �� �JJ �i