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APPLICATION FOR PERMIT V' i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ! PERMIT EXPIRES 1 YEAR 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. Job Address City Lot Size PM Owner's NamAddress a 7 � d„- CQ "- '--_----- Phone 2eZ Contractor Address 'I1 a�� License No. Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SE NK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA S7RUCTION SPEC( ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications 0 f l Public ❑ Other a Depth of Grout Seal Type of Grout I I Irrigation --Approx. i I Eastern Surface Seal Installed by - _ Repair Work Done ❑ Typ ump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material (Below 50'1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION Ll DESTRUCTION (No septic system permitted if public seweris available within 200 feet.) 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 t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 9 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS i l Depth Size Number SUMPS ®_ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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: "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-" 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 req,ire inspections. Complete drawing on reverse �side. . .-Signed X f>7Q/S �C✓ .•.crc - Title: �Lf� _'-' Date: FOR DEPARTMENT USE ONLY Application Accepted by -�! r Date 613 12 7 Area � — Pit or Grout Inspection by bate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EK 13-24(REV.I/K5) _ -Yyi U'X�^ a� - EH 1�-za 1