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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 ISSU (Complete in Triplicate) hel �!L Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta a work herein described. This a ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the t e San Joaquin Local Health District. 1 Job Address 1 City , Lot Size PM I Owner's Name 1l f ! Address __ � �� fo V Phone t .._. Contractor L�/ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' " E3 Open Bottom „ ❑ Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Tiacy Type of Casing Specifications Fl Public Ll Other i C7 Deka Depth of Grout Seal Type of Grout 1 i Irrigation, —.Approx. Depth I l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I,I DESTRUCTION (No Septic system permitted if p y p public sower 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundatioh Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I. FILTER BED ❑ Distance'to nearest: Well Foundation Property Line j SEEPAGE PITS I I Depth Size Number \ f SUMPS L� Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS ❑...-. f1 , 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 1" f rules and regulations of the San Joaquin Local Health Di§trict. 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 shalt 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 1 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 required inspections. omplete drawing on reverse side. Signed X Title: ri �' � Date: 2.d a a FOR DEPARTMENT USE ONLY Application Accepted by batt 2_a__6iy Area ' V Pit or Grout Inspection b.1 Date /yam Final Inspection by Additional Comments- 0 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 i INFO AMOUNT DUE AMOUNTRE�MITTED CASH RECEIVED BY DATE PERMiT'NO. +.EH13-241REV.1/A51 �0� EH 14-26 t.fY l.� f\ 5—, L-'1,.