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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I. 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. Job Address / - City -Lot Size C M Owner's Name 4Address I� Phone L� / contractor 1' Address License No. Phone'y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ p C� PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of sing Specifications l'1 Public n Other C1 Delta Depth of G ut Seal Type of Grout I I Irrigation Approx. Depth i Delta/ Easte Surface Saal I tailed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fillet Material (Below 50'1 t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONX (No septic system permitted if public sewer is 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 �r SEPTIC TANK ❑ Type/Mfg H IN11 I I CAll,".4 L L) No. Compartments t� PKG. TREATMENT PLT. ❑ r—11 Y11 p� �}hp�+ Method of Disposal Distance to nearestPerIlmaVay�t ?�4f�r, without Property Line beifig eE)MnInted or inspected LEACHING LINE ❑ No. & Length of lines §"length/size FILTER BED L1Distance to nearesttJy –amjrOnmi. o a ion 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 Di§trict. 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fol 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 must call for all uire inspections. Complete drawing on reverse side. P(..Signed X Title: Date: OR PARTMENT USE ONLY Application Accepted by 11,11, 1 Date ' S—\_( '0� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 4_X1 f ❑ 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 4 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �7 i.EH 18-241REV.1/H 51 e�� J _.60 / 9rCJ� 3 i EH 14-28 c 4