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" y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r � z 1601 E. HAZE' TON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM � I r Owner's Name Address Phone Contractor I Address icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 1 DESTRUCTION [D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE ANK ._SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a tion Dia. 0 ell Casing LJ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications I Cl Public 17 CI Delta Depth of Grout Seal of Grout I Irrigation prox: I Depth I i 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 50') TYPE OF SFPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION i I DESTRUCTION ( No septic system permitted if public sewer is U e 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: Water table depth SEPTIC TANK 171 Type/Mf g Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance fo nearest: Well Foundation Property Line • # LEACHING LINE ❑ No. & Length of fines Total length/size j FILTER BED ❑ Distance fo nearest: Wel! Foundation Property Line SEEPAGE PITS ( I Depth I 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 Di§trict. 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 toibecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I ce -fy that iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali n $ 1 The applicant 11 11 f r I require 'Fd ions. Complete drawing on reverse side. Signed Title: "_ ~� r Date: I -FOR DEPARTMENT USE ONLY Application Accepted by ' Date '� Area Pit or Grout Inspection by ' k�!! Date Final Inspection by Date ` rJ Additional Comments: �'V►".r { „_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 3-7104 ❑ Tracy 835-6385 Applicant TReturn 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 CASH RECEIVER BY GATE PERMIT'NO. ♦ EH13-14(REV.t/H5) EH 14-28 r!!7