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APPLICATION FOR PERMIT g7j SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601,E. HAZEL I ON 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 a 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 Addresses J O UM .L.LY' ��" City ` ' Lot Size PM / C -_ Phone Owner's Name R4CtJ+ Address f Contractor Set 4 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 i FOUNDATION AGRICULTURE WELL OTHER WELL P INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP S ❑ Industrial ❑"Open Bottom ❑ Manteca DJ a Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tra Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout E ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by Repan Work Do Type of Pump H.P. State Work Done l Well Des 'ti j❑ Well Diameter Seating Material"(top 50') _I I Depth Filler Material (Below 501 TYPE'OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.} t I Installation :will serve: Residence— Commercial_ Other :E I O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK } ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal b Distance to nearest: Well Foundation Property Line 1 r. LEACHING LINE ❑ No. & Length of lines i Total length/size f ' FILTER BEDI ❑ Distance to nearest: Well -Foundation Property Line r *" � - SEEPAGE PITS ❑ Depth Size Number SUMPSt ❑ Distance to nearest: Well Foundation ° Property Line DISPOSALrPONDS ❑ 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 regulationsiof the San Joaquin Local Health District41-w - Home owner br 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."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- tion laws of California." T plicant must call for all requd inspections. Complete drawing on reverse side. Signed Title: Date: _c FOR DEPARTMENT USE ONLY �� Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection by Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.1/8 31 ��.. _t3 �O EH 14-26