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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT ff 1601 E. HAZE T ON 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 Cit Lot Size 17— PM Owner's Name dress Phone Contractor a Address License No. Phone_ PE OF WELL/ WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION GRICULTURE W OTHER WELt PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom teca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casing Specifications 11 Public ❑ 0th ❑ Delta Depth Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface S Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material Itop 501 Q I' Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17. REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT:PLT. ❑ K Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ �No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number ~ SUMPS Cl 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 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." 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." I The applicant for all required in ctions. Complete drawing on reverse side. SignedTitle: Date: { AEQR DEPARTMENT USE ONLY t r Application Accepted by •lY�G1;,:. IA. .4 xO� _ Date Y b �0 Area ` Pit or Grout Inspection by Date Final I spaction by Date ,0 Z r.47 Additional Comments: G -r - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 !4�3 AMpUNT DUE AMOUNT REMITTED C 3H RECEIVED BY DATE PERMIT'NO. em— t EH 1 -241REV.Fir<51S i- EH 144-28 w ccc___JJJrrr/// r