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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (Complete in Triplicate) .-1,. i�la 0.j •"1i � 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 Regulationsof the San Joaquin Local Health District. Jab Address '' �� City° �' Lot Sizew IL��'l'� UPM Owner's Nam �4ddress - - r Phone I � Contractor Address License No. Phone TYP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,❑- a PUMP INSTALLATION E] SYSTEM REPAIR F1k d OTHE DISTANCE TO NEA SEPTIC TANK-- - —" _SEWER LINES 4 � DISPOSAL FLO. PROP. LINE � ' DATION AGRICULTURE WELL 9_THER WELL PITS/SUMPS INTENDED USE TYPE OF W L PROBLEM AREA CONSTR N SPECIFICATIONS ~Vl D Industrial ❑ Open Bottom an Dia of Well Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public ❑ Other �elta Depth of Grout Seal Type of Grout O Irrigation JApproxern a Seal Installed by Repair Work Donel�❑ Type mp , H.P. State Work Done Well Destruction ❑� all Diamet r ' Sealing Material*(top 50') t 7 Depth f i Filler Material (Below 501.. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is 5 vailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Chara f soil to a'depth`of 3 feet: T ,ter table depth x- - If SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to t: Well foundation Property Line LEACHING LINE C) No. & Lerigth of Ii Total length/size FILTER BED ❑ Distance t rest: Well Foun Property Line SEEPAGE PITS Depth ' Size Number SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ I a I hereby certify that I have prepared thisl 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$ecome subject to workman's compensation laws of Calif omia.".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 applican st call f all requir in ctions. Complete drawing on reverse /side. Signed Title: _ l Date: 2— 27 FOR OEPARTIMENT USE ONLY Application Accepted by Date l Z�` Area Pit or Grout Inspection b Date Final Inspection by Date J , 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 INFOAMOUNT DUE. AMOUNT REMITTED DK RECEIVED BY DATE PERMIT•NO. FEE f + EH 13424 1 REV.i/a 51 EH 1428