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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEi ON AVE., STOCKTON, CA 8 Telephone 12091 466-6781 11PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'J . r{ fGomplete in Triplicate) • r ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or stall 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. } City Lot Size PM Job Address r` � I Owner's Na Address Phone rg ContractorIR dress C7' License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D SAL FL17. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA C RUCTION SPECIFICATIONS DIndustrial ElOpen Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra ypa of Casing Specifications ,1,.Public T ❑ Other f elta D th'af Grout Seal Type of Grout - I i Irrigation - - m —_Approx.,D I I Eastern Surfa a Seal Installed by Repair Work Done ❑ Type of P p H.P. State Work Done Well Destruction ❑ Wel Ititer' Sealing.Material (top 501 � Depth -Fillet Material I Below 50'1 delI TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION l 1 DESTRUCTION (No septic system m permitted if public sewer is availabInstallation will serve: Residence' 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. 171I Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Le�gth of lines Total length/size a FILTER BED ❑ Distance,to nearest: Well Foundation Property Line W I SEEPAGE PITS 11 Depth 1 Size Number SUMPS L] Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that l have prepared this application rules and regulations of the San Joaquin Local Health Di1trict. 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." Contractors 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." j r The applicant must all required inspections. Complete drawing on reverse side. Signed �1 ills: C0 7-1 � Date: r i a .FOR DEPARTMENT USE ONLY t {/ Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 —4pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 t� FEE AMOUNT U� AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT'NO. INFO �• / �r +.EH 13-24 1 REV.1/8 5Y ��: '/''� --)-S f EH 14-28 -