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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Al Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r�1 fJaJ (Complete in Triplicate) Application is hereby mad_a 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District, Job Address tr City �� Lot SizePO y` 3Qo PM f r ' r SIS Owner's Name �i j�t� + - � Address Phone 1-142— & ` Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST':-SEPTIC TANK SEWER LINES -DISPOSAL FL'D. PROP. LINE FOUNDATION AGRICULTURE WELL I)HER.WELL.. - - PITS/SUMPS INTENDED USE TYPE OF WELL PROBL EA CONS ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack �❑ Tracy Typ f Casing Specifications M Public ❑ Other Cl D Depth o taut Seal Type of Grout _ I I Irrigation _.-Approx. Depth Eastern Surface Seal Installed by Repair Work Done 0 Type of Pum H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: .NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) ! Installation will serve: Residence Commercial Other Number of living units: -of bedrooms _ . , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. © Method of Disposal Distance to nearest: Well Foundation Property Line . i LEACHING LINE ❑ No- & Length of linesJ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl a 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: "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 applicantm t call for all required-inspections. Comp to drawing on reverse side. Signed X Title: (�-2.� r� Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date p Additional Comments: 41 ElStk 466-6781 ❑ Lodi 36,9-3'621 ❑ 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.FEE r INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. r EH 13-24(REV.I/n sl EH 14-2$ I