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{ APPLICATION FOR PERMITZ 1411 SAN JOAQUIN LOCAL HEALTH DISTRICT /�. 1601 E. HAZE T ON AVE., STOCKTON, CA jt Lr Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.f r fJob ,Address `� f City � of Size J PM Owner's Name ` e r� Address U r J Phone ?-5 �3J Contractor._ Lj� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-7 PUMP INSTALLATION ❑ SYSTEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA ONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom L] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other FI Delta th of Grout Seal Type of Grout I Irrigation Approx. Depth I I E ern Su a Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done �. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 FIEPAIA/ADDITION l 1 DESTRUCTION i I (No septic sstem permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms VN Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal [� Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L7 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 employ an permit is issued, I shall not p y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting s compensasignature i� certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's tion laws of California." �1 The applicant m st call for all require inspections. Complete drawing on reverse side. Signed Title: Date: _ �~ FOR DEPARTMENT USE ONLY J ' Date ?- 7—, r � Application Accepted by � t Area Pit or Grout Inspection by Date Final Inspection by Datetf-,7 f� Additional Comments: o i 0 q S ,e r ryl LL 0 Stk 466-6781 0 Lodi 369-3621 ❑ 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 CK RECEIVED BY INFO CASH DATE PERMIT NO. ♦ EH 13-24)REV. �+ 7 EH 1428 � 7