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I Jp * APPLICATION FOR PERMIT .. , . SAN JOAQUIN LOCAL HEALTH DISTRICT ! = R 1601 E. WAZELTON AVE., STOCKTON, CA k t Telephone (209) 466-678 1 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 ! 4. 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 i 'Local Health District. ►. ' Lot Size PM Job Address _' t City CAt f Addresses rT • k Phone Owner's Name' r' - - ` l �� r Contractor Address License No. { TYPE OF WELL/PUMP:' . NEW WELL 171WELL REPLACEMENT El DESTRU ID Ei PUMP INSTALLATION fl SYSTEM REPAIR ❑ OTHER 171 , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS " TION SPECIFICATIONS INTENDED USE TYPE OF WELL P ,! ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation w Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing r ,--„ Specifications FI Public FI Other ❑ Delta Depth of Grout Seal jType of Grout I i Irrigation _ rox. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done -❑ pe of Pump H.P. State Work Done EI Well Destruction Well Diameter Sealing Material(top 501 r fj Depth Filler Material (Below 50') 11+ TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 t f EPAIRIADDITION {.:I DESTRUCTION (No septic system-permitted if public sewer is ;,r• -— vailable within 200 feet.I 4�. r Installation will serve: Residence— Commercial— Other"— N' V t i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments q PKG. TREATMENT PLT. 11 Method of Disposal + Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C I Depth Size Number F SUMPS ❑ Distance to nearest: Well Foundation Property Line �i DISPOSAL PONDS ❑ II. uEl 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. I 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, t 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, I shall employ persons subject to workman's compensa- tion laws of Calif a.' The applicant It for II required inspections. Complete drawing on reverse side. Signed X Title: Date: ^/ + FOR DEPARTMENT USE ONLY a Application Accepted by Dat /11 . Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f""` - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E! Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s l a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 1REV.l i a 57 1 96_77 EH 14-2e l