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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT � ' � 4 1601 E. HAZEL T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ptf`ID j } �} (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 l Local Health District. Job Address 1 t J City Lot Size r IV V PM y Owner's Name 4 Address Phone 1 License._ (-'No, ess _ Pone Contractor --- i TYPE OF WELL/PUMP: NEW WELL fl WELL REPLACEMENT ❑ T DESTRUCTION Ll . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OT LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA--'CONST N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca �. of.Well,Excavation -- -Dist of Well Casing k ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications I ❑ Public ❑ Other elta k Depth of Grout Seal . Type of Grout ❑ Irrigation _Ap epth ❑ Eastern r Surface Seal Installed by 111 H p I State Work Done— Repair Work Done ❑ e of Pump n ( Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 E- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO D TRUCTI (No septic system permitted if public sewer is oval ble within 2 feet.l L ', 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 I Capacity No. Compartments l PKG. TREATMENT PLT. ❑ .'" Method of Disposal Distance to.nearest: Well Foundation Property Line LEACHING LINE ❑• `NO. & Length of lines T - otal length/size ' FILTER BED ❑ .Distance-to nearest: Well { Foundation Property Line s . r SEEPAGE PITS ElDepth Size Number_ r SUMPS QI Distance to.nearest: .-.. ..Well- Foundation )Property Line DISPOSAL PONDS ❑I t .l ii I hereby certify that I have prepared this application and that the work will be done in accocerdanwith San Joaquin county ordinances, state laws, and rules and regulations of the jSan 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 shalk employ persons:subject to workman's compensa- tion laws of California.". The applicant ust call for l reqjlri�nspections. Complete drawing on reverse side.rSigned (Title: C�� Date: t+ � t FOR'DEPARTMENT USE ONLY Application Accepted by Date — Area A 4 Pit or Grout Inspection Date Fin Inspection by Date Additional Comments:_ - �s ❑ Stk 466-6781 ❑ Lodi 369-3621 d Manteca -71 ❑ Tracy 835-6385 tie Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. INFO ON + EH 13.24 1REV.f i R 5) EH 14-29 -