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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E.- HAZEL T ON AVE., STOCKTON, CA ti q b Telephone 12091 486-6781 � � f ]PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is heoeby 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 Or Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "\1 V"", S City,� M Lot Size PM Job Address W� Owner's Name Address Phone ' G� Q 4 - Address o k,") F C icense No. � Phone Contractor TYPE OF WELL/PUMP: _ NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONStRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i - ❑ Graa- -'*-� O 7iacy Type of Casing Specifications r ❑ Domestic/Private vel Pack" F ix - - Depth of Grout Seal Type of Grout ("I Public Cl Other 171 Delta I Irrigation r w--Approx.:.Depth I ! Eastern Surface Seal Installed by Repair Work Done ❑-- Type of Pump H_P. State Work Done tl + I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RE}PAIRIADDITION l I DESTRUCTION t o septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence �fCommercial! Other'-- Number ther`- Number of living units: Nu4er of bedrooms t Character of soil to a depth of 3(seta Water table depth ,-. • .,,,,;,, SEPTIC TANK El 'Capacity —___- No. Compartments PKG. TREATMENT PLT. ❑ . 4 Method of Disposal 71 Distance to nearest: Well Foundation Property Line kn °+ t Total length/size LEACHING LINE ❑ No. & Length of lines.. �' , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ] Depth z Size _ Number SUMPS Cl 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. 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 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- s of Califon i Tha applic st call �all ulna HsCo te d arawing on averse 'se. I Signe ps ions Title: Date: FEPARTMENT.USE_QNLY,,,1 ^d,,.. -- . �` � II` Application Accepted by Date ea € Pit or Grout Inspection by Date . Final Inspection by ©at 95UPIr Additional Comments: _ l 'r` ❑ Stk,.466 fi781 ❑xLodi 369 3621r-❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. HaMton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DU,E AMOUNT REMITTED 3H RECEIVED 8Y DATE PERMIT NO. 1 INFO I a EH 13.24(REV.I/H 5) EH 14-28