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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT Lf 1601 E. HAZELTON AVE., STOCKTON, CA cl� G- Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L 1 Job Address 313 1 City T .Lot Size PM Owner's Name Address YYa Phone Contractor e— Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (` - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "V ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {l Public ❑ Other Ll Delta Depth of Grout Seal '- Type of Grout_—_ I rout — I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted*ifpublicsewer is available within-200.feet.! i 3 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Ccimpartrinents PKG. TREATMENT PLT. Ll Distance of Disposal .- Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation --Property Line . SEEPAGE PITS 11 Depth _ Size Number 1 SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 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." Contractors 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- tionlaws of C fornia." �* i r � ^ r The applican ust call for all required ins tions. Complete drawing on reverse side. y� Signed X l Title: G' Date: FOR DEPARTMENT USE ONLY , Application Accepted by Final IDate �� ^ Area_ � t Pit or Grout Inspection by Date nspection by Date 14 !� Additional Comments: r ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'A n FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMITNO. INFO ` a.EH13-24 1REV,t/n 51 5 EH f4-28