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s i, APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone {209) 466-6781 is PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (Complete in Triplicate) l�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 welt/pump and the Rules and Regulations of the San Joaquin fJ Local Health District. i +Job Address `]d City t Size PM '.Owner's Name �ql",Address / / Phone I'Contractor Address License No. Phone E�TYPE OF WELL/ P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q a . PUMP INSTEl SYSTEM REPAIR ❑ OTHER ❑ IDISTANCE TO NEAREST: S C TANK SEWER LINES D AL FLD. PROP. LINE' FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS . i INTENDED USE TYPE O>Packo AREA CO UCTION SPECIFICATIONS EI Industrial El Open Bia. of Well Excavation Dia. of Well Casing �I❑ Domestic/Private Q Gravel Type of Casing Specifications , ❑ Public El Other Depth of Grout Seal Type of Grout �i❑ Irrigation �4ppSurface Seal Installed byRepair Work Done ❑ Type of P .P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') U Depth Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is �i -available within 200 feet.) E Installation will serve: Residence_ Commercial— Other Number of living uni Number of bedrooms I Edd Character of soil to a hof 3 feet: Water table depth jSEPTIC TANK Q Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal li Distance to nea Well oundwi.n Property Line I{ ' LEACHING LINE ❑ No. & Length of line Total length/size FILTER BED ❑ Distance to n St. Well Foundation Property Line SEEPAGE PITS ❑ D th Size Number ' SUMPSDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. E, 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 i! employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature li 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." u The applicant ust call for all required inspect n Complete drawing on reverse side. a fl Ei Signed Title: Date: Ei F R DEPARTMENT USE ONLY !� Application Accepted b Date Area 63 .I ;i Pit or Grout Inspection y Date Final Inspection by Date Additional Comments• E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 Q tracy 835-6385 " !� 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 CK RECEIVED BY DATE PERMIT'NO. fl INFO CASH + EH 13-24(REV.1/e 5) .ms s �-,�' 6,J� J EH 1428 1 A