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APPLICATION 15iOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mad_a 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 r Local Health District. P e City g Lot Size 6L� PM Job Address t Address Phone � Owner's Name Contractor Address License Nq._��___— Pho TYPE OF.WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYS EM REPAIR EI OTHER LJ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE T0.NEAREST: SEPTIC TAMC- , FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS EM AR CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I F-1Industrial ❑ Open Bottom��---�=❑.Man c Dia. of Well Excavation T e of Casin Specifications i ❑ Domestic/Private ❑ Gravel Pack ElTra YP g Type of Grout i"1 Public Ll Other if Ll elta� Depth of Grout Seal I I Irrigation ° _Approx Depth i ! Eastern Surface Seal Installed by � i H p State Work Done Repair Work Done O Type of Pump Well Destruction L] Well Diameter Sealing Material Itop 501 Depth ` . Filler Material (Below 50'1 { l TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIRIADDITION I I DESTRUCTION aNailabpewit within feeftjed if public sewer is Installation will serve: Residence_ Commercial_ Other, Number of living units: ; Number of bedrooms R WaAD Character of soil to a depth'of 3 feet: "�SEPTIC TANK ❑ Type/MfgCapacity No.MePKG. TREATMENT PLT. ❑ e a.Distance to nearest: Well Foundation Property LEACHING LINE ❑ No. & Length of lines Total length/size Distance'to nearest: Well �. FoundationProperty r FILTER BED _ SEEPAGE PITS I I Depth Size Number Property Line SUMPS L� Distance to nearest: Well Foundation P rt1+ ! DISPOSAL PONDS ❑ '' 4 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, an 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 laws of California." Contractor's hiring or sub-contracting signature r certifies the fallowing; "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:pplica m st II f 11 required i ctions. Complete drawing on reverse side. fXSignd X Title: Date: FOR DEPARTMENT USE ONLY t :e ~ � Application Accepted by_ _ Date Aea Date " = DatPi -inspection y f I Pit or Grout Inspect ori eby} e Additional Comments: i ❑ Stk 466-6781,. 0 Lodi 369-3621 ❑ marteca 823-7104 Cl Tracy 83 5 a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 r CK ffKAMOUNT DUEE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. r� —y {- i �g ^� %` r EH 13-24[REV.s 5N �� CZ(� G>�' F Vy�r �� 11�,ZS l � U! l a EH 14-ZB