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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CAS` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DA E ISSUED (Complete in Triplicate) application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app 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 made Loco! Health District. t- r City Lot Size 3 PM Job Address C• D Phone �( Address � Owner's Naini Address License No. L -Phone Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES ---� DISPOSAL FLD. PROP. LINE DISTANCE TO ST: SEPTIC TANK- PITSISUMPS ION AGRICULTURE WELL OT TYPE OF WELL M AREA CTION SPECIFICATIONS INTENDED USE Of Well Excavation Dia. i f Well Casing r ❑ Open Bottom eco ❑ industrial Type of a Specifications Private ❑ Gravel ❑ Tracy Tye of Grout Pn P ❑ Domestic/ Depth of Grout Seal - Q ther ❑ Delta FNS M Public Surface Seal Installed by f. I l Irrigation -—Approx. Depth t I Eastern State Work Done "1 H,P, _ �., :.�,�..�.,..R—• -- T - Repair rk Done ❑ Type of Pump - ._. —=, v -Well Diameter Sealing Material (top 50'1 Well Destruction C1 Depth Filler Material (Below 50') TYPE OF SEPTIC WOflK: NEW INSTALLATION I_i REPAIR/ADDITION t 1 *DESTRUCTION aNal`sepei Hs`system peeeitted if public Bawer is lOther Installation will serve: Residence�— Commercial� ., Number of living units: Number o1 be Water table depth { Character of soil to a depth of 3 feet: Capacity— No. Compartments F SEPTIC TANK ❑ Type/Mfg Method of Disposal i. PKG. TREATMENT PLT. ❑ Property,Line ` Distance to nearest: Well Foundation i j F Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED. CI Distance to nearest: Well Foundation Number SEEPAGE PITS I 1 Depth �;ize Property Line j Foundation SUMPS Ll Distance to nearest: Well DISPOSAL PONDS ❑ this application - I hereby certify that I have prepared s 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 such manner as to become subject to workman's compensation Paws 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'issuad, I shall employ persons subject to workman's compensa tion laws of California." } The applicant must call for all r quired ins ctions. Complete drawing on reverse side. Date: Title: r Signed X FOR DEPARTMENT USE ONLY Date �� Area k Application Accepted by � � I DateY Final Inspection by Pit or Grout inspection Dat Additional Comm(nts: ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental,Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO ♦.EH 1324(REV..1/H 5) EH 14-26