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". APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES TYEAR FROM DATE ISSUED i (Complete in Triplicate) Application is he+eby made to.he 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 i Local Health District. 1 i Job Address &Aix= City Lot Size PM Owner's Name Address �� `�'� Phone 91 315 - � '1M w Contractor I. Address License No. Phone TYPE OF WELL/PUMP: il� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D f UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ di DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS INTENDED USE ;TYPE OF WELL. PROBLEM A CONSTRUCTION SPECIFICATIONS k 17 Industrial Open Bottom ❑ Man a Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ acy Type of Casing Specifications t 1-1 Public I I`Other Delta Depth of Grout Seal Type of Grout I I Irrigation I�u .Approx. Depth l I Eastern Surface Seal Installed by F - �l Repair Work Done ❑ Type of Pump H,P. State Work Done 1I 171Well Destruction Well Diameter Sealing Material flop 501 I Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is iiNavailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: SII Number of bedrooms "I � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 1 Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ r: Method of Disposal IN ! Distance to nearest: Well Foundation Property Line LEACHING LINE ❑1 No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth s Size ' Number SUMPS ❑I. Distance to nearest: Well f Foundation Property Line d DISPOSAL PONDS 01 I hereby certify that i have prepared this application and that the work will 6e done in accordance with San Joaquin county ordinances, state laws, and, rules and regulations of thel�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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 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 compensa- tion laws of California." III I The applican must call for alt required inspections'-Complete drawing on reverse side. �j Signed Title: L`! Date: FOR QEPARTMENT USE ONLY _ �--. --.--- —— Application Accepted by J[ Date V �� Area Pit or Grout Inspection Date Final Inspection by � -- Date Additional Comments: ❑ Stk 466-6781 El 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 AA/IOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EH13-24[REV.t/R51 (, , • EH 14-2e �° //