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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE;TON AVE., STOCKTON, CA 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 made in compliance with San'! oaquin 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 I I City a . Lot Size PM Owner's NamePhone r I! Address l i — 2 Contractor Address License No, Phone TYPE OF WELL/PUMP: ;i`i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK>E3a ER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONCULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WEREA CONST TION SPECIFICATIONS ❑ Industrial 17 Open Bottom of Well Excavation Dia. of Well Casing L1 Domestic/Private ❑}Gravel Pack Type of Casing Specifications I Public Cl OtherDepth of Grout Seal Type of GroutI 1 Irrigation �� .-Approx. DSurface Seal Installed by Repair Work Done ❑ Type of Pump . State Work DoneWell Destruction ❑ Well Diameteraling M erial (top 501 �I. ' Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION LI DESTRUCTIONINo septic system permitted if public sewer is vailable within 200 feet) i Installation will serve: Residence— Commercial_ Other l Number of living units: . Number of bedrooms Character of soil to a depthlof 3 feet: Water table depth SEPTIC TANK' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ NI Method of Disposal + Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED El Distance to nearest: Well Foundation Property Line $ SEEPAGE PITS I'I Depth Size Number SUMPS Cl 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 agentl�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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant all for all/req ired ins ctions. Complete drawing on reverse side, i� r Signed $ 2 Title: Date: 67 If FOR DEPARTMENT USE ONLY f �h Application Accepted by _ Date/ ��- • 1 Area Pit or Grout inspectionIn Date Final Inspection by Date �Z��Ste/ r vAdditional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies ta; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEi AMOUNT DUE AMOUNT NT REMITTED RECEIVED BY GATE PERMIT NO. ASH w + EH 13-24{PEV.vs5i EH 14-4 .I� 1