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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t A� 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Cornplete 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 of Size PM Al Owner's Name n/ Address Phone Contractor_ ecf L.k/1gf3 Address License No.3"4J__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DEST AaT-tON ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1OTHERL3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LIVE- FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS,` INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications f'1 Public n Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation prox. Depth I 1 Eastern Surface Seal Installed by v Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION {No septic system permitted if public sewer is available within 200 feet-1 Installation will serve: Residence_ Commercial— Other_ Number of living units: Number of bedrooms Character of soil to a dR, of 3 feet: 0 hWater table depth SEPTIC TANK Type/Mfg Capacity No. Compartments Y PKG. TREATMENT PLT. C1 s Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ N9. &Lenth of lines — Total length/size FILTER BED ❑� Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 F Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 California." The applicant ust call for all required inspections. Complete drawing on reverse side. Signed X Title: 01, Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area '] Pit or Grout Inspectio Dat_e�ff��-�Jal Inspe�byo,,�, Date f• Additional Comments: W ❑ Stk 466-6781 ❑ Lodi 369- 1 i❑ Manteca 823-7104 C1 Tracy. 835 6385 Applicant- Return all copies to: Environmental Health Permit/ServiAs 1601 E.-Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMIEECASH] RECEIVED BY DATE PERMII'Np, INFO �7 i EM 14-26