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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 JAPERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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.41.1 Job Address F!1 `' d' �` - City Lot Size PM I Owner's Name Address Phone Contractor's Name License No. z -T 3q3Phone �+ ' 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottorri. '� ❑ Manteca: , ° Dia.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, Y�.J'o❑ Tracy`-JN, 1Type of Casing Specifications ❑ Public ❑ Other i C1Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�� Commercial_ Other � Number of living units:/ Number of bed ooms Character of soil to a depth of 3 feet: "' Wates table depth SEPTIC TANK ❑ Type/Mfg!. Capacity No. Compartments Q PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line # 1 4 LEACHING LINE ❑ No. & Length of lines Jotai-lengthYsize ^� '$ �. o FILTER BED '� Distance toI nearest: Well Pr,o erty Line i« SEEPAGE PITS ❑ Depth Size - Numtier-: SUMPS ❑ Distance to nearest: Well - —Foundation I—Property Line DISPOSAL PONDS' ❑ 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 er I rules and regulations of the San Joaquin1ocal Health District. f ,✓ Home owner-or licensed agent's signature certifies the following:"'1 certify that'in the- rformance_o�f-the'warkfor which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws-of•Caliiornia." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this,peimit is issued, I shall employ persons subject to workman's compensa- tion laws of California." �"�� `'^ r: The applicant us ca r all re 'ed ' specti ns. Complete drawing on,revKerse side Fr Signed Title., s Date: r, FOR DEPARTMEF USE ONLY 7�'� Application Accepted by } Date "'r+ ��` Area Pit or Grout Inspection by ! Date0Final Inspection b %J Date oil _ Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantas 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health�Pr�ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 6 ' - i c: C FEE AMOUNT DUE I AMOUNT REMITTED CASH REOEIVED BY DATE PERMIT`NO. INFO 1 - - /�te'//a_ 5d-�� + EH 13-241REV.10/831 40O `7 r EH 1428 f �