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AFfOLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STbCKTON, CA Telephone (209) 466-6781 ter ter PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) L Application is Hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo in described s Ica is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump nd the Rules and Regulations of San Joaquin Local Health District. 17 L �r ,S'' �rr � ^� Cit r a Lot Size J� �M Job Address Y Owner's Name �`+ gl /, -- Address G,-/, Z ^�� Ra`�'` Phone '�(° U ��~ 4 „Fn _;�1, _ Contractor Address .`,f. `` "" 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. P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED UStr TYPE OF WELL PROBLEM AREA } CONSTRUCTION SPEC TIONS ' ❑ Industrial ❑ Open o ❑ Manteca Dia. of Wisin tion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy g Specifications T [ E Public ❑ Other n Delt Depth of Graut ea Type of Grout I i Irrigation µ vel I Eastern SurfaceS.,. Installed by Repair Work Done QST a of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth . Filler Material i8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f l DESTRUCTION ( (No septic system permitted if public sewer is �l I r available within 200 feet.i Installation will serve: Residence_ Commercial s Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: # Water table depth J SEPTIC TANK ❑ Type/Mfg Capacity ' 'No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line it l LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Size _ Number w r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 applicant m for all require �sete drawing on reverse side. Signed X J � :Title: __ Date: FOR DEPARTMENT USE ONLY i GApplication Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date r Additional Comment ❑ 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, Slk., CA 95201 FEE AMOUNT AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH p i EH13-241REV.ri II 51 f EH 14-28 l