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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 � , Telephone (209) 466-6781 .. 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 with unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance San Joaquin Co Local Health District. 1 of Size PM Job Address Phone Owner's Name ' Address ` p r " . k License No.—N60'—N6� Phone Contractor Address t TYPE OF WELL/PUMP: iNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1. DISPOSAL FLD. PROP. LINE ' DISTANCE TO NEAREST: SEPTIC TA NK SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL OT INTENDED USE TYPE OF WELL PROBLEM AREA CONST SPECIFICATIONS Dia. of Well Casing ' ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation ' T e of Casin Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tr yp g Type of Grout — {-1 Public i-1 Other Delta Depth of Grout Seal I I Irrigation Depth I 1 Eastern Surface Seal Installed by - r H p State Work Done Repair Work Done ype of Pump + Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth 1 Filler Material (Below 501o ` V� TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION l l DESTRUCTION (Nailabletrwthinstem e200 teetltjed if public sewer is (1 Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms r Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK )< Type INlfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. fl I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &'Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS l 1 Depth I Size Number ! SUMPS CI 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: "l 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 must call for required ins ctions. omplete drawing on reverse side. X-77 h X Signed X Title: Data: (T #y FOR DEPARTMENT USE ONLY '�"r,Lk_ i 1 `-� Area 03 Application Accepted h Date Pit or Grout Inspection.by ate Final Inspection by Date I'Llp Additional Comments Y, ❑ 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 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NG INFOg. + EH 13-241REV,r/951 I � 2 J EH U-28