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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address _ + � "` f f` "c' City - Lot Size PM Owner's Name n T rDx�Address —/ 1 A`L' Phone Contractor Address z-91- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCEO ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR INE n -FOUNpATION _ AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF WEL OBLEM ARE STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Te Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac LJ Tracy Casing Specifications f`i Public [1'0 ❑ Delta Depth of Grout Type of Grout I I irrigation �..Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work D ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 p TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION l 1 DESTRUCTIONY INo septic system permitted if public sewer is 1f available within 200 feet.) Installation will serve: Residence_ Commercial_ other Number of living units: Number of bedrooms_ u 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 LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑ Distance to clearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number- SUMPS L] 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 I 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 io 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, /.shall employ persons subject to workman's compensa- tion laws of California." Thea ant ust call for all required inspections. Complete drawing on reverse side. Sig ed Title: _- Dater FOR DEPARTMENT USE ONLY Application Accepted by �-� _ Date 4�; / Area � f 1 Pit or Grout Inspection b �y Date Final Inspection by ' t/ DateC F Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED /C K RECEIVED BY DATE �PIE�R/fMIT'NO. + EH 13-241REV.1/,A5f •J/7D ! �'�" X/ EH 14-2e !(� CCCJJJ !lIJJJ