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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. s Job Address �.� City J Lot Size PM i Owner's Name Address 4 Phone Contractor ddress f 7 o r License No.r �53_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEW R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI UL E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMA CONSTRUCTION SPECIFICATIONS w 11 Industrial ❑ Open Bottom �.❑.Ma ca. Dia:of-Well.Excavation Dia. of Well Casing 11 Domestic I Private E] Gravel Pack Elacy Type of Casing Specifications 1'1 Public ❑ Other . Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Dane ❑ Type of Pump H.P. State Work Done_ ---� Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Belo ) T TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l DESTRUCTION I I INo septic system permitted if puhlic sewer is -- – - --a ilable wilthin 200 feet.I Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A 09 Water table depth SEPTIC TANK ❑ Type/Mfg r IQL�x capacity 20 Q No. Compartments PKG. TREATMENT PLT. ❑ Method of D1spo Distance to nearest: Well No NO Foundation ,Property Line _ s LEACHING LINE ❑ No. & Length of lines T tal length/size FILTER BED ❑ Distance to nearest: Well Foundati Prope Line� fr SEEPAGE PITS 11 Depth Size Ob Number SUMPS Ll Distance to nea st: Well V w 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 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,t shall employ persons subject to workman's compensa- tion laws of California." The applic 79 m4,st call I required i pections. Complete drawing on reverse side. SignedX Title: Date: /2 FOR DEPARTMENT USE ONLY r Application Accepted by Date �D Area m�[ r Pit or Grout Inspection by �/ Date Final Inspection by Dately Additional Comments: tJ`� S 1 Z- 1ehe ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 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 CASH CK RECEIVED BY DATE PERMIT'NO. +.EH1324{REV.i/K 51 I[ -� ' LFII C! f `co `_ EH 14-26 ""` '��. 1 If.J V r.Jd'