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r ' APPLICATION FOR PERMIT -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Cvi,._t-,;j- j>1 :�f.� PERMIT EXPIRES 1'YEAR FROM DATE ISSUED N11b t .t1�}�+�t��r•,., j (Complete in Triplicate) �1 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 ply i Owner's Name ddress Phone s_'10/ Y, , Contractor6"1 Address0 S36, -L License No>� l I Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION "'"AGR[CULTORE WELL" LL' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CO ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack racy- Type of Casing Specifications 1-1 Public ❑ Other Cl Del'ta'��it r�+D.e�pth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern�Y `' t Surface Seal Installed by `t Repair Work Do Type of Pump H,P. �= State Work Done_ Well D ction ❑ Well Diameter Sealing Material ftop 50'1 Depth ""Filler-Material--(Below 50'f TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION 1 I DESTRUCTIO fNo septic system permitted if public sewer is 1 r available within 200 feet.) , installation will serve: Residence_ Commercial_-�OtherJ Number of living units: Number of bedrooms 'Character of soil to a depthof3 feet: ,r Water table depth SEPTIC TANK Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ f ,. } Method of Disposal 1 f a Distance to nearest Well Foundation Property Line LEACHING LINE ❑ }No. & Length of lines i Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line s SEEPAGE PITS [ I Depth Size I Number SUMPS L1 Distance to nearest: WellFoundation Property Line DISPOSAL PONDS ❑ I 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 f rules and regulations of the San Joaquin Local Health District. j 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for allrequired inspections. Complete drawing on reverse side. Signed l Title: Date: w v FOR DEPARTMENT USE ONLY Application Accepted by Date Area yr Pit or Grout Inspection Date 1/ `r'� ��Final Inspection by Date Additional Comments: K ❑ Stk 466-6781 ❑ 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 Y FEE AMOUNT DUE AMOUNT REMITTED [X� RECEIVED BY DATE PERMIT'NO. INFO 1 + EH13-24(REV,iin5) EH 14 -28