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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L7f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. F_ i Job Address ( City Lot Size 390 pM i )p rr I O H`er's Name �t 1 l rir1'S Qtr() Address I ` A. Contractor Address License NO. Phone t TY E•OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION'© '"'r^^4 SYSTEM REPAIR ❑ *. OTHER ❑ DISTANCE TO NEAREST.:`SEPTlC TANK - ' SEWER LINES - "DISPOSAL FLO. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ""TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial -0 Open Bottom 15Manteca Dia. of Well Excavation ❑ Domestic/Private "[D ell of Well Casing Gravel Pack ❑ Tracy Type of Casing Specifications P Public ;f.,,),Cl Other C] Delta Depth of Grout Seal p' I I Irrigation t q Type of Grout _ �.. pprox. Depth I I Eastern Surface Seal Installed by Repair Work'Done ❑ Type of Pump — -..�._—..,..-H.P- State Work Done_ Wel! Destruction f ❑ Welf Diameter Sealing Material (top 50')th De �-'i - p Filler Material ieelow 50'1 +� TYPE OF SEPTICWORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1 1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will)serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil 0a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ DistaMethod of Disposal Distance to nearest: Well Foundation Property Line . r I LEACHING LINE ❑ No. & Length of lines Total length/size ° FILTER BED f ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number - s SUMPS L ❑ Distance to nearest: Well Foundation DISPOSAL'PONDS . ❑ Property Line 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: "l certify that in the performance of the work for which this permit is issued, I shall employ i tion laws of California- t P y parsons subject to workman's compansa The applicant must call for all required inspections. Completed wing on reverse side. Signed t. Title: Date: i FOR.DEPARTMENT USE ONLY R �I° E r Application Accepted by- f 1! t� Date Area I Pit or Grout Inspection b'' 4 t Date yr y rr Finakinspection by 4 + ! I s Additional Common x _ ' ❑ Stk 466-6781 Lodi :369-3621 ❑ Manteca'823 7104 :❑Itracy 835-6385 t I Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave P.O. Box 2009, Stk., CA 95201 1 F1 AMOUNT DUE - .AMOUNT REMITTED - C i ° INFO SH RECEIVED BY , DATE PERM17'Wi °+.EH 13-24(REV.I/n 6) EH 1t-2a 3