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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT V4z o1�► . 1601 E. HAZE T ON AVE., STOCKTON, CA R Telephone (209) 465-6781 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 City Lot Size PM Owner's Name Address J�BJ � Phone J Contractor Address License No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL { PROBLEM AREA CON ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack-•�- t ❑ Type of Casing Specifications 1`1 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation ox: Depth l 1 Eastern Surface Seal Installed by < r Repair Work Done ype of Pump H.P. State Work Done _ Well Destruc ❑ Well Diameter Sealing Material Itop 50'1 A(,� Depth tt Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I OESTRUCTIO ' I (No septic system permitted if public sewer is avertable within 200 feet.) Installation will serve:" Residence!I` Commercial— Other Number of living units: Number of bedrooms I » Character of sail 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 ❑ No. & Lenigth of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I F 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."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 "fornia." '1 The applica t ust g2II or all requirAd i tions. Complete drawing on reverse side. Signed Title_ Date: 5— FOR EPARTMENT USE ONLY Application Accepted by ,,L A � as� O.,.., c, - _,Date 5– L-'a) Area Pit or Grout Inspection by ` Date Final Inspection by &ZeDate l/ Additional Comments: ❑ Stk 466.6781 ❑ 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 FEEI INFO AMOUNT DUE AMOUNT REMITTED GSH RECEIVED BY DATE / PERMIT'NO. + EH 13.24 IREV.1/n 5135 sv U 1 3 !r/ `4�f EH 14-2e q J y' ahJS? '` Vd