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APPLICA-h FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA [� Telephone (209) 466-6781 ; e PO, ��"`^�` ;1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j� (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 Col my Ordinance No.549 for sewage or No. 1862 for well/pump and the flutes and Regulations of the San Joaquin Local Health District. .4x, it L its, Cit �.�© .Lot Size PM y Job Address J � ~. rS Owner ,, ,n/1� r� _ Phone 3 G's Name Q Address �_ g Phone Contractor _ t Contractor Address �~ tO�- License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER "❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;; rf `'-•FOUNDATION{ AGRICULTURE WELL OTHER WELt PITS/SUMPS INTENDED USE--"_TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca r Dia. of WeII Excavation." S pia. of Well Casing El Industrial _' Type of-&sin Specifications IK Domestic!Private ❑ Gravel Pack., 1],Tracy - g Type of Grout ❑ Public ❑ Othert ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth Eastern Surfl Seal Installed by p " SC H.P. State Work Done Repair Work Done Type of Pum t. Well Destruction ❑ Well Diameter Sealing Material (top 501 Filler Material IBelow 50'M �' } Depth • TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑:;aNailabseptic cyst m rented if public sewer is vle Installation will serve: Residence— 'Commercial` Other Number of living units: Number of bedrooms Water table-depth Character of soil to a depth of.3 feet: " SEPTIC TANK ❑ Type/Mfg Capacity ��5j; No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to:nearest: Well Foundation Property Line _ r LEACHING LINE ❑ No. & Length of lines Total lengthlsize f FILTER BED 1-5 Distance�to nearest: Well Foundation Property�Linev � s SEEPAGE PITS ❑ Depth-4" Size Number SUMPS ❑s Distance" 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. 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 at become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r 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." 1 The appii st call for all re'" inspecti s. Go late drawing on reverse side. Signed X ` Title: Date: [ [T w FOR DEPARTMENT USE ONLY I. � � Area I Application Accepted by Date Data Pit or Grout Inspection by "f' Date Final Inspection by y' 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 l 'mr FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE } ` PERMIT NO. CASH INFO ' + EH 13-241REV.i/H51 .- EH 1428