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* .�. APPLICATION FOR PERMITDTHs CSAN JOAQUIN LOCAL HEALTH DISTRI T ��1601 E. HAZELTON AVE., STOCKTON, A Telephone (209) 466-6781 ` /�GJPERMIT EXPIRES 1 YEAR FROM DATE SSUED 'yw�G,I(Complete in Triplicate) r� �j vApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins the workd. This appllication ismade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t les of the San Joaqui Local Health District. * s Job Address City IL Lot Size ` PM Owner's NamAddress --C-,C Z.e's.e�' 4 Phone Contractor Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHERS DISTANCE TO NEA SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE F TION AGRICULTURE WELL OTHE L PITS/SUMPS INTENDED USE TYPE OF WE PROBLEM AREA CONSTRUCTION IFlCATIONS ❑ industrial ❑ Open Bottom ❑ a Dia. o xcava"on Dia. of Well Casing © Domestic/Private F1 Gravel Pack Ll Tracy a of Casing Specifications f`l Public L-] Other 171 Delta Dept rout Seal Type of Grout —_— I I Irrigation _Approx. Depth astern Surface Seal In d by _ Repair Work Done [ITy p H.P. Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material !Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.? Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms m _r 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 –4 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 ❑ 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."Contractor's hiring or subcontracting 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 alt r quired�ins ctions. Complete drawing on reverse side. , Signed X -� Title: ate: _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Date -Final Inspection by Date Yhxty Additional Comments: �� r~� U / � 0 U G 0. C] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 / S 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 H RECEIVED BY DATE PERMIT'NO. r EH14U WWWW -26(REV.I/n 5] 3<�~ �� EH -2a .�