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APPLICATION FOR PERMIT .I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 11 Telephone (209) 466-67$1 ri PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is heEeby 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. 1B62 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ('. .,�,/ 4 111 �� Job Address &©D,r •3� 1 - City- Lot Size .. PM l dress Phone Owner's Name �!� r iR' - Contractor ' &LdJ Address '� �� ri License No. 11_r1Vd Phone TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION ❑ r. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROFILE A CONSTRU N SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype o sing Specifications {-1 Public F1 .Other N Delta Depth of Grou al Type of Grout — I I IrrigationApprox. Depth t I Eas n Surface Seal Instal d by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50'1 G TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) .E Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms r Character of soil to a depth�h.f 3 feet: Water table depth z SEPTIC TANK ❑ ype/Mig Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. 171 Distance to nearest.' Well ' Foundation Property Line LEACHING LINE ❑ allo. & Length of lines Total length/size ` FILTER BED ❑ ('Distance to nearest: Well Foundation Property Line SEEPAGE PITS Il (Depth Size Number I 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'ltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th4 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." The applica ust call or ail re ire i spections. Complete drawing on reverse side. Signed X Title: Date: �, ks FOR DEPARTMENT USE ONLY ) Application Accepted by ' _.—__ Date Area E t Pit or Grout Inspection b Dane Final Inspection by Date Additional Comments: B ! i, R� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant - Return all copies71o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520.1: {�\y 1I _ t-EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. INFO !I +.EH 13-241Rt:v.1/851 II EH 14-26 . I