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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. ;I Job Address Cit Lot Size PM Owner's Name :Address . ,� PjJ Phone Contractor, dress S License No. Phone 1 S TYPE OF WELL/PUMP: NEW W LL L] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SY REPAIR:❑ --------OTHER,❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER IN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU RE LWELLr F OTHER WELL------r— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR "CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing ❑ Domestic/Private ❑ Gfavel Pack ❑ Trac T �e of Casin I Y YR 9 Specifications I I Public ■ J Cl Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation � J �.q – pprox.IDepth ( I Eas rn Surface Seal Installed by Repair Work Done ❑ Type of Pump1 H.p, , State Work Done_ 0; Well Destruction ❑ Well Diameter� 'Sealing Material (top 50') Depth Filler Material IBeI w 50'1 ¢ TYPE OF SEPTIC WORK: NEW INSTALLATION i'I REPAIR/AbDITION DESTRUCTION i I (No septic system permitted if pub sewer is 1 _ available ithin.200 feet.) V Installation will serve: Residence_t Commercial�S ther Y Number of living units: Number of bedrooms ` ` Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ — -- I !` ' ( Method of Disposal L Distance to!nearest: Well Foundation` J` *Propeerty Line 4 f' LEACHING LINE ❑ No. & Length of lines t _ t gih/siz r FILTER BED ❑ Distance to nearest: Well Foundation o rty ine l C SEEPAGE PITS 11 Depth I + ,. if p Size Number , SUMPS ❑r 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, 1 shall not employ any person in su6hmanner 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 th'e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for.al quired'i�s ipections. Complete d wing on reverse side. r 1 wy ~� Sig ned Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by pate '2 Area JPit or Grout Inspection by Date— Final Inspection by Date , Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-362111 ❑ Manteca 823-7104 ❑ Tracy, 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ' AMOUNT REMITTED CK CASH RECEIVED 6Y DATE PERMIT ND. +. (REV.1 EH 14-26 /K 51 +Zs` 0 C?O •��S