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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA q6k Telephone (209) 466-6781. PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �� 1 (Complete in Triplicate) �I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrRSed. This"'appklcation 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. r _ /W o �. l 7 C� r`�/y ' ! `( Lot Size f x�� PM Job Address ( City � ' . � I f / f� - r� / -U *" : Phone Owner's Name 1 C) Address \ S •� Address License No. Phone_ Contractor " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLfl. PROP. LINE ...� FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS F INTENDED USE TYPEQF WELL PROBLEM AREA CONSTR SPECIFICATIONS ,❑ Industrialf ❑ Open Bo ❑ Manteca ia- of Well Excavation Dia. of Well Casing F1 Domestic I Private ❑ Gravel Pack` Tr Type of Casing Specifications — FI Public t l Other - Delta Depth of Grout Seal Type of Grout I I irrigation ;._Appro 'ph 11 Eastern Surface 1@d bV Repair Work Done ❑ Type ump H.P. State Work Done _ Well Destruction ❑ _Diameter Sealing Material Itop 50'1 i Depth -Filter Material (Below 501 - TYPE OF,SEPTIC WORK: NEW INSTALLATION t 1 RFPAIR/ADDITION I DESTRUCTIO Navailabpti cystithin m permitted if public sewer is Installation-will serve: Residence— Commercial— Other— Number ther Number of living-units: Number of bedrooms Character of soil to a"bepth of 3 feet: Water table depth SEPTIC TANK, V❑ `Type/Mfg Capacity No. Compartments G, Method of Disposal PKG, TREATMENT PLT. ❑ f I"; Distance to nearest: Well Foundation Property Line Total len th/size LEACHING LINE.-,'-�` 17-1 No. & Length of lines o� g I FILTER BED -F a FI-r 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 ❑ 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 Dt%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 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 required inspections. Complete drawing on reverse side. Signed Title: `� �'t>�`r Date- FOR DEPARTMENT USE ONLY Application Accepted by by Area J�_... Pit or Grout Inspecti Date Final Inspection y Dat z+ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Retur(n'atl copies to: Environmental Health Permit/Servi as 1 1 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMD NT REMITTED CK 4 RECEIVED BY DATE PERMIT NO. INFO r.EH 13-24(REV.5/H 5) EH 14-2a