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-'� APPLICATION FOR PERMIT s SAN. JOAUUIN 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. Job Address ' t/`' City Lot Size_ PM Owner's Name _ Address _ �W �/1 J��-�y Phone _ Contractor ; _Address_- License No. Phone r TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT IFICATIONS ' C Industrial ID Open Bottom ❑ Manteca Well Excavation P Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications f 1 Public D Other (� Delta Depth of Grout Seal _. Type o} Grout _ 7' — I I Irrigation ox. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump _ H.P. _ State Work Done'__ - WkA ell Des on ❑ Well Diameter _ Sealing Material-Itop 50') r ti Depth. Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: ' NEW INSTALLATION I I REPAIR/ADDITION L I DESTRUCTION + (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence' 1 ti ; Commercial_ r Other' Number of living units:,__— Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundation Property Line- LEACHING LINE L1 No. & Length of lines '. - ti Total length/size- FILI ER BED ❑ Distance to nearest: Well Foundation Property Line N SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation _ Property Line . DISPOSAL PONDS ❑ :! 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."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." nt ,us call or all req ed inspections. Complete drawing on r erre side. '7 Signed X Title: �p ` J 0 �/ Data: u FOR DEPARTMENT USE ONLY Application Accepted by j Date rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 L Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 v I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMDUNT REMITTED RECEIVED BY DATE EPERMIT'No.jINFO CA H+.EH 14-7AlREV.I/nsi � �� OV .�