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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED x (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for welllpum and t ules and Regulations of the San Joaquin Local Health District.' City Lot Size Job Address ~ Address + Phone Owner's Name AN, Contractor Address CTR �j License N Phone TYPE OF WELLIPUMP: NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications F1 1 Other F1 Delta Depth of Grout Seal Type of Grout Public , Irrigation µ Approx. Depth i I Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. Slate Work Done Well Destruction ❑ Well DiametIer Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION I DESTRUCTION l 1 INo septic system permitted if public seedJis l available within 200 feet.) Installation will serve: Residence`_ Commercial_ Others/, ' Number of living units: Number of bedrooms """""""– �. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Capacity No. Compartments F al PKG. TREATMENT PLT. d Method of Dispos � ,/ `� Distance to nearest: Well Xt oundation Property Line �— " l LEACHING LINE _❑ No- & Length of lines Total length/siza FILTER BED ❑ Distance to nearest: Well ndabon� Property ize y S" Number SEEPAGE PITS i I Depth y SUMPS ❑ Distance to nearest:` ,,We • Foundation_. —_. Property Line DISPOSAL PONDS ❑ A I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and . F rules and regulations of the San Joaquin Local Health Disrict. I Hume owner or licensed agent's signature certifies the following: 'Sl 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`workrtian'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 s fo all re uir nspections. C plate drawing a v rse side. Jj Signed X Title: Date:/ FOR DEPARTMENT USE ONLY Application Accepted by Data 0 �10 0 Area r out Inspection by at Final Inspectiongby. 1 A dttioo� omments: P ��o�� Q�` L1Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 1335 63x5 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box-2009, Stk., CA 95201 I CK 1 _ r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 'a + EH 13-24 tREV.E/x 51 - EH 14-26