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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) aquin Local Health District for a permit to construct and/or install the work herein described.This application is Application is he(eby made to the San Jo made in compliance with San Joaquin County Ordinance No._54 for sew ge or No. 18862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -1 7Q �t �1�""" f [ 7�,��/ U 5-170 �- 9 City�r�"L Lot Size PM Job Address Owner's Name � Address �� / Phone Contractor L, Address License No 420—Phone )] 4 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. PROP. LINE DISNCE TO NEAREST: SEPTIC TANK SEWER LINES TAPITS/SUMPS YFOUNDATION 1 AGRICULTURE WELL — OTHER WELL USE TYPE OF WELL wPROBLEM AREA CONS PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Wel! Casing acy Type of Casing Specifications ❑ Domestic/Private ❑ Grave! Pack Type of Grout ❑ Public F1 Other ❑ Delta Depth of Grout Seal I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P._. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 501 Depth Filler Material 16elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i i DESTRUCTION I I aNallabptic s stemhin rmit}ed if ppublic sewer is Installation 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 E) TypelMfg Capacity i�m No. Compartments " PKG. TREATMENT PLT. ❑ x I Method of Disposal �} f ��f 1 J Distance to nearest: � Well ZQ Foundation�r-.— Property Line gf1 " LEACHING LONE Nr No. & Length of lines Total length/size �( FILTER BED ❑ Distance to nearest: Well-� Foundation. /A Property Line J SEEPAGE PITS Depth Size Number � r SUMPS L-1 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: "l 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, I shall employ persons subject to workman's compensa �. tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 'J Title: � � Date: FO DEPARTMENT USE ONLY � � � Area Application Accepted by Date Date r - Finpbate X24 Pit or Grout Inspection by�g /�.o/cj�/-7 a! Insection by - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED INFO W/ f EH 13-24(HEV.t/ s7 V Q W (n EH 14-2a r