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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i # 1601 E. HAZEL T ON AVE., STOCKTON, CA �5 Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. k1 Job Address City Lot Size .. PM Owner's Name /"� Address ��rog;'�"' 's Phone 4 Contractor Address -1License No.� Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIA AGRICULTURE WELL OTHE a INTENDED USE TYPE OF WELL PROBLEM AREA TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications 1-1 Public Other (1 Delta Depth of Grout Seat Type of Grout _ -as I I Irrigation Approx.'Depth I I Eastern Surface Seal Installed by _ Repair Work Do Type of Pump H.P. State Work Done_ 1 Well D uction EJWell Diameter Sealing Material [top 50') Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I ! DESTRUCTION {No septic system permitted if public sewer is available within 200 feet./ VVV Installation will serve: Residence I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of.Disposal Distance to nearest: Weil Foundation Property Line l } I s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth i Size Number SUMPS L] Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ � j 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 the certifies the following:"I certify that in performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applican must call for all required inspections. Complete drawing on rev se sl e. Signed 501 Title: T —r// Date: 6 FOR DEPARTMENT USE ONLY Application Accepted by /''-:c- r Date Are Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: —P-46 ❑ 51k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE MOUNT REMITTED RECEIVE(}BY BATE 1k,2 'NO. INFO �`] f ;� r EH 13-24(REV.i/na) EH 14-26 r vv