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I 1 x � APPLICATION FOR PERMIT 441 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE— STOCKTON, CA n�� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .4 , (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. f ' 1 � 1 Job Address e cit � Lot Size .� x I PM Owner's Name j{)}�, Address Phone Contractor S Address License No. Phone_ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL 0 ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS [2Industrial ❑ Open Bottom 1-1Mantec Dia. of Dia. of Well Casing Well Excavation � ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I 1 Irrigation _Approx. Depth I Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done Well uction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I (Nosbe1ic system permitted if public sewer is avaInstallation 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size IIS FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll ' 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." i ?Signed X icant ust call all required insp ctionitle:s. Complete drawing on re se side. Date: FOR DEPARTMENT USE ONLY a, nr,Rr�( Date Area Application Accepted bar —��:••� _2 3-V Pit or Grout Inspection by Date Final Inspection by Data ! V V i Additional Comments: f\Jo I ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ,�`` + EH 13-241r1EV.1, 5) V 1 EH 14.28