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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL H EALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` 41 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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �] �I Jab Address cJ / ' ! J�41/�� Cit /'' Y / Lot Size PM Owner's Name !+�/a� Address Phone s� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 01 WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR Q R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. ROP. LINE OUNDATION AGRICULTURE WELL R PITS/SUMPS _ INTENDED USE TYPE L PROBLEM AREA CONSTRUECIFICATIONS ❑ Industrial ❑ Open Bottom anteca el! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public f 1 Other to f Grout Seal Type of Grout _. I Irrigation g" �._Approx: D I I Eastern Surface Seal d by Repair Work Done ❑ Type of p H.P. 5ta c Done Well Destruction ❑ We iometer Sealing Material (top 50'1 I. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is 1 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 SEPTIC TANK E3Type/Mfg Capacity No. Compartments q PKG. TREATMENT PLT. L1No. of Disposal Distance to nearest: Well Foundation Property Line M I LEACHING LINE ❑ No. & Length of fines Total length/size lv FILTER BED C7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth i Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EJ 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 M 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 ust call. or-all.require inspections-Complete,drawing.on-reverse-side?----- Signed X Title: i. Date: 1 � FOR DEPARTiNENT USE ONLY � Application Accepted by Date rea } i Pit or Grout Inspectio y date Final Inspection by � f v Date ff �! Additional Comments: / ( O / CJ ❑ Stk -4 - 466-6781 Ef Lodi 369-3621 ❑ Manteca 823-7104 v racy 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 INFO CASH RECEIVED BY DATEPERMIT 'NO. + EH 43-24 IREV. /n 5)EH 4-28 i —117