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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 ISSUED (Complete in Triplicate) Application is ho"eby 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 City ' Lot Size PM ! Owner's Name Address Phone ,4, sl Contractor Address icense P h o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL 0 - L PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications \ ) M Public, ❑ {)they f ,,_�l.Delta. —Depth of Grout Seal _Type of Grout _. �- t I I Irrigation, pprox. Depth I Eastern Surface Seal Installed by i Repair Work Done Type of Pump _ H.P. State Work Done Well D ion Y'' ❑ Well Diameter{ Sealing Material (top 50') r. Depth Filler Materiel {Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAFRt ADOITION 1.1 OESTRUCTIO (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence `=" Commercial�L Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: ) Water table depth SEPTIC TANK ❑ Type/Mf 9 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation l Property Line LEACHING LINE ❑ No. & Length of lines r "�,j Total length/size FILTER BED C7 Distance to nearest: Well - Foundation,�-A ! Property Line SEEPAGE PITS l I Depth f Size I ! NumE�er SUMPS 11 Distance toy nearest: Well Foundation t 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 Dihtrict. 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, I shall employ persons subject to workman's compensa- tion laws of California." The applica must call for all requi ed ins coons. Complete drawing on r rse side. Sig - _..._ Title: 1T i _—Date: �. `i° 1 FOR DEPARTMENT USE ONLY Application Accepted by l' i Date ^ `1 Araa j c Pit or Grout Inspection by Date Final Inspection b ' Date . Additional Comments: © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUN `REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV. EH 1428 �(/y' (Y�LC`-„ / `•�I 7/F�i