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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZEL T ON AVE., STOCKTON CA s Telephone (209) 466.6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED i I (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. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. - Job Address City Lot Size Ir PM Owner's Name Address Phone Contractor's Name Na Phone TYPE OF WELL/PUMP: Zz5_ >41 EW WELL L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ElWell Diameter I Sealing Material (top 501) e h Depth L Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION EPAlR/ADDITI) ESTRUCTION (No septic system permitted if public sewer is Is P-7414— (01 _ ,,.available within 200 feet.) Installation will serve: Residence Commercial_Other Number of living units: Number of bedrooms y D� Character of sail to a depth of 3 feet:; ! Water table depth SEPTIC TANK ❑ Type/Mfg CapaciNo. Compartments PKG. TREATMENT PLT. © 1 _ Method of Disposal . Distance to nearest: Well_- �. Foundation _ Property Line - LEACHING LINE ❑ No. & Lengthoflines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation vt Property Line SEEPAGE PITS ❑ Depth j Size Number F SUMPS ❑ Distance to nearest: Well ' 'Foundation. Al Property Line DISPOSAL PONDS ❑ f' 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. Q 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature tion certi laws of fies the following: llow n California."I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa Il The applicant must call for II required inspections. Compl to drawing on r r side. i. �` Signed Title: �+ _ Date: a FOR DEPARTMENT USE ONLY ' {t Application Accepted by /C.,-Date �! �Ar d Date Final Inspection by Date 7 �1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH �oo ) s, + EH 24 IREV.10!831 W too n EH 1426 t" o 0 9�