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APPLICATION FOR PERMIT W4 I SAN JOAQU N LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone, (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ti (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. { a 1 Job Address l ..f�� w City Lot Size PM A. Owner's Name Address Phone �M_ r !Contractor_ �" 1 f Addres GC� License No Phone TYPE OF WELL/PUMP: :-- a W WELL El - :--_WELL.REPLACEMENT ❑,.,'' .DESTRUCTION ❑ , PUMP INSTAL ION ❑ SYSTEM REPAIR OTHER ❑ -� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE 0��OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROB M A CONSTRUCTION SPECIFICATIONS r ❑ Industrial F-1 Open Bottom ❑ ec Dia..of Well Excavation ❑ Domestic/Private ❑ Gravel Pa ¢ Dia. of Well Casing ck ❑ Tracy Type of Casing 'ts`.. _ Specifications r Public ` ❑ Othe ❑ Delta Depth of Grout Seal ` Type of Grout irrigation pprox. Depth ❑ Eastern S ace Seal Installed by Repair Work Done ❑ _ ype of Pump �I P' '"` ---�-State Work Done Well Destruction ❑ Well Diameter i Sealing Material (top 50'1 .: Depth Filler Material (Below 501 j :ter STYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONc septic system permitted if public sewer is �^ ilatile Within.200 feet.] _ Installation will serve: Residence ' Commercial Other I ! r, •�� ; 1 its: umber of bedroomsa `� Number of living un ,N '* Character of soil'to.a depth of,3 feet:! SEPTIC TANK sty Water table depth I t ElTyp f9 Capacity 9 S,tNo.=Compartments PKG. TREATMENT PLT. Ll T-�...,�,.Method of Disposal Distance to nearest: Well Foundation 1 Property Line LEACHING LINE ❑ No. & Length of lines f Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f Property Eine SEEPAGE PITS ❑ Depth Size Number a j sum isF-1 Distance'to nearest: Well Foundation 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 District: - + Home owner or licensed agent's signature certifies the following: 9 9 g: "i certify that 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.taws 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." ;I % It t The applicant must call for all required inspections. Cpmplete drawing on reverse side. G Signed , Title: ' Date: i OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Fina( Inspection by Dat /� 1 Additional Comments: !!� � i 6o Z,� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ 16ky 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT OUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CASH (REV. EH 14.26 35