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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601- E. HAZEL T 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. `' w Job Address 8 cityi''" Lot Size' PM Owner's Name :.. -Address Phone Contractor XZ Address r ►l o� -License No. Phone TYPE OF WELL/PUMP: WEW WELL ❑ WELL REPLACEMENT. LI DESTRUCTION ❑ (� PUMP INSTAL LATIO SYSTEM REPAIR ❑ OTHER ❑ S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OInd trial E3 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Zomestic/Private ❑ Gravel Pack I7301rracy Type of Casing Specifications D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth EIEastern Surface Seal Installed by oe Repair Work Done e__-Type of Pump, H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms- k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number SUMPS D 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that iri 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 must call for all required inspections. Complete drawing on reverse side. Signed Title:' amu, Dale,®_ E16 IFOR DEPARTMENT USE ONLY Application Accepted by Date 1/hft�?_-�Area Ap Pit or Grout Inspection by Date Final Inspection by Date /-Zk cry - Additional Comments- El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BBYY i DATE y�P{EERRMET`NO. ' a EH13-241REV.1/657 Ar OQr �� OO �� '�✓ ;/x�( / PLaC1- *., EH 1428 �L ��J✓ aC3✓ Uvv LJC!