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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 3 Yx Telephone (209).466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.jn 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 i 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 f Owner's Name Address r . Phone Contractor Address License No. Pho e YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTAL LAT N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE >WELLPROBL AR CONSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open ❑ Ma a Dia. ofWell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graveracy Type df CasingSpecifications f l Public ❑ OtherCl Delta th of Grout Seal Type of Grout € 1 Irrigation —ApI I Eastern Su a Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') E Depth Filler Material (Below 50') Q n TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADOITION I 1 DESTRUCTIO (No septic system permitted it public sewer is 1\•�V' available within 200 feet.) _Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms a... Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ClMeth d o a Disposal {F Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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 c`otripensation laws of California."Contractor's hiring or sub-contracting signature 4 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 re ed,i ctions.'Complete ara'6 on-reverse side. _ Signed - Title:. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date, 6� EAraa' O 2 2 s�$7 � -F ,J Pit or Grout lnspection by Date Final Inspection by Datge`�" Additional Comments: 4y. rt 0M1 ❑ 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.D. Box 2009, Stk., CA 95201 r a - c FEE F INFO .' AMOUNT DUE MOUNT REMITTED 'CASHK 9,f A' RECEIVED BY DATE PERMIT NO. " pVtJy t + EH 13-24(REV.i i n 5) ,^., / d EH 14-28