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l APPLICATION FOR PERMIT ; J SAN, JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE T ON AVE., STOCKTON, CA t 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. f Job Address City Lot Size PM t Owner's Name Address YW • Phone Contractor ; Address License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT IFICATIONS ' r ❑ Industrial D Open Bottom ❑ Manteca "Well Excavation P Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications i 4 M Public ❑ Other ❑ Delta Depth of Grout Seal —� Type of Grout I I Irrigation rox. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump fl.P. State Work Done' kA_ Well Des on ❑ Well Diameter Sealing' Material-(top 501 r Depth. Filler Material (Below 60'1 = TYPE OF SEPTIC WORK: ' NEW INSTALLATION I 1 REPAIR/ADDITION1.1 DESTRUCTION INo septic system permitted if public sewer is available.within 200 feet.) Installation will serve: Resdence; Commercial_ Other" Number of living units:, Number of bedrooms t Character of..it to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ !'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ : Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE Cl No. & Length of lines ! - _f Total length/size _ i FIL7 ER BED ❑ 11 Distance to nearest: Well Foundation Property Line it SEEPAGE;PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E) :! 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." nt us call or all req ed inypections. Complete drawing on r arse side, Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 456-6781 L] 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 RECEIVED BY DATE PERMIT'N0. INFO CA H EH 14-20 24fFEV.1in5l 1 .1