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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT El S, 1601 E. HAZEL i ON AVE., STOCKTON, CA N o�4 i Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ,L (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District" Job Address City_ Lot Size PM Owner's Name -/� Address _47t- � Contract 1Addre C 3�9;�,_- License N ` l� Phor S �! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F ROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing I, ❑ Domestic/ ❑ Gravel Pack racy Type of Casing Specifications F1 Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work D Type of Pump H.P._ State Work Done Well ) ction ❑ Well Diameter Sealing Material (top 501 Depth - t Filler Material (Below 501— TYPE OF SEPTIC WORR< NEW'INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION (Na septic system permitted if public sewer is f it %, available within 2b6 feet.) Installation will serve: ResidenceCommercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ *--------- -----Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Lenth of lines Length �" ,Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation v �i� Property Line f � I SEEPAGE PITS f I Depth Size �._Number SUMPS - Ll Distance to nearest: Well- Foundation Property Line s DISPOSAL PONDS ❑ 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, Horne owner or licensed agent's signature certifies the fallowing: "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 corhorisatidh-laws of California:"'Conirac oor'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 calf for all required ins tions. Complete drawing on rever ide. Sig Title Date: 1 b v 1 R DEPARTMENT USE ONLY Application Accepted by _��, , �� V"� \ �_� s Date Area v Pit or Grout Inspection by Date Final Inspection by G- Date I r • i Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE a 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i a. E"1344 IREV,I/N 51 r- EH 14-28 ^' - f