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APPLICATION FOR PERMIT J`SAN JOAQUIN LOCAL HEALTH DISTRICT' W`LS �"� �o - `t b� 1601 E_ HAZELTON AVE., STOCKTON, CA Telephone (209)-466-6781 t 671— j PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED (Complete in Triplicate) I� �.t, Application a to the Sa Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joa i 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 City Lot Size PM Owner's Address 191(c b ;* - ; A; Phone Contract a Address icense No hone 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Domestic/ Private M Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ LJ Upen Bottom ❑ Gravel Pack ❑ Other —Approx. Depth Type of Pump Well Diameter Depth TYPE OF SEPTIC WORK: NEW INSTALLA ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing n Delta Depth of Grout Seal I I Eastern Surface Seal Installed by H. P. State Work Done Sealing Material (top 50'1 Filler Material (Below 50') I 1 REPAIR/ADOITION 1 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Dia. of Well Casing Specifications Type of Grout Installation will serve: Residence , Commerciar — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ to Capacity. Water table depth _ No, Compartments Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 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. i Home owner or iicen agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not t employ any person i uch manner as to become jest to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the foil "1 certify that in the ps ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ia." Th call for all requ' to dr_ e. t Signed '�' Title: Date: Dater OR EPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date ,Fina! I ton y Oate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante -7104 ❑ Tra 0 _ _ s Applicant - Return all copies to: Environmental Health Pemtit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Six., CA 95201 a EH 13-241REV. i/x5 EH 14.26 IFED EE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT* NO. 1 134 -C,� � i /tri ictfed „��.5 4.