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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone Q09) 466-6781 No PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NO 1 "u, kx Application is hereby made to Ithe 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 oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,q ! V [[� Job Address � City Lot Size PM Owner's Nam Address Phone ` s Contractor Address&" + �' (( icense N — l Phone TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER IT5/SUMPS t INTENDED USE STYPE OF WELL—PROBLEM AREA-----GQNSTf �SPECIFIC-A7iONS-----. ❑ Industrial EJ:.Open Bottom ❑ Manteca la. of WeII.Excavation Dia. of Well Casing �1 ❑ Domestic/Private Q;Gravel Pack cy Type of Casing k Specifications M Public n Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation III prox. Depth t I Eastern ,Surface Seal Installed by - Repair Work Done ype of Pump H.P. �' State Work Done._ Well Destruc ' ❑ Well Diameter. Sealing Material Itop 50'I D�pth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION INo septic system permitted if public sewer is vailable within 200 feet.I Installation will serve: Residence iCommercial_ 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. Compartments ' PKG. TREATMENT PLT.-E! ti Method of Disposal Distance to nearest: Well Foundation Property Line `_ f I l i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line I . i SEEPAGE PITS I I Depth Size ; Number r SUMPS L� i 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 rules and regulations of the 1San 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 perforiiriance of the work for which this permit is issued,t shell'employ persons subject to workman's compensa- tion laws of California," The appli must call forall requir s ctio Complete drawing on r rso std JI .— Signe %. Title: _y Date: -0EPARTMENT USE ONLY ` v0 Application Accepted by _ . Date —`-' `t Area wp Pit or Grout Inspection by Date Final Inspection1w Date d 6 Additional Comments: I ❑ Silk 466-6781 ❑ Lodi 369-3621,/ n❑ Manteca R 10 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 ir IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. lltd ♦`EH 13-24�(fiEV.I/n 5) 1`t� EH 14.26 CAZf::�