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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �7 Job Address '/ �(� �� - ! City Lot Size PM Owner's Name Address �/'� J Phone Contractor Address License No.�Phone_ (�51L�-. TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION>0 S; �. PUMTr1NSTA1L-A7T0N-0- SYSTEM-REPAIR'-3- " —0THER-E3 - - —" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE u , - FOUNDATION Z7 \AGRk"CULTURE`W' ELL�- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _ PRORLEM�AREA CONSTRU�TI.ON SPECIFICATIONS ❑ Industrial ❑-Open 8�ftom l3 Ma�steia a-af Wr=1t>xcavation ------.7 Dia.-of-Well-Casing--- -- ❑ Domestic/Private" �, Gravel Pack ❑ Tracy Type of Casing F SpetoCifications ❑ Public *_1 Ot}ie�* `} .1t C� Delia Depth of Grout Seal ' Type of Grout I I Irrig'ation ��Applox. Depth I 1 Eastem� Surface Seal Installed by F - Repair Work Done ❑ �Tyipe of Ptamp; 1,1H.P. State Work Done _ � �Al S:Z&,L Well Destruction Well Diarrie sr.. .. f�...._, Sealing Material (to �AiL.5 �� Depth �..Filfer Matenal IB Iow,50'i R TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION 1.1 DESTRUCTION I I (No eptic system permitted if public sewer is i avai able within 200 feet.l Installation will serve: Residence Commercial Commercial Other ` y Number of living units: Number of bedrooms "Nt Character of soil to a depth of 3 foht:�3 Water table d4pth c SEPTIC TANK ❑')Typo/Mfg� .. j r - Capacity � No. Compartments � PKG. TREATMENT PLT ❑ ! Method of Disposal " '_" iista;ce to,nearest: 41v-.11 Foundation Prop ny LinLEACHING LINE ❑ No. &Ler9-th,of lines Total length size ° FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS I I Depth Size Number ) f� SUMPS L1 Distance to nearest: Well Foundation Property Lin 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 whichrthis permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of California."I 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 requ' ns. Complete drawing on revers side. ` # t Signed X Title: Dat FOR DEPARTMENT USE ON j4! Area is ' Application Accepted by Date � Pit or Grout Inspection b Date Final Ins action by o I `_ ` 1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369- 21 V ❑ Man eca 823-7104 6kacV 835-6385 plica t Return all copies to: En rronmental Health Permit/Service�/1601 E. Hpzplion Ay., P.O. Box'201)9 Stk., CAiW01 �� 7yl�ysrj 7nc�G� awl' SZ' r aa�owte� rz 6o'J�a�,, oC ho�a- Cr .,- u� ��,(. '[�a'rj a IZ Zo.�w, �' 1. o$� U • FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. CASH INFO N R� +.EH13-24(REV.riwSY , EH-1426 ; j i