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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r a Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' _ (Complete in Triplicate) l 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 v Al Cit Lot Size PM Owner's Name Address Phone ECVU !� / / Contractor� Address dy ...yzf��_- 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 FLO. PROP. LINE R FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 71 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION I I DESTRUCTIO 'INo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet:- Water table depth r SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS FI Depth Size Number SUMPS L71 Distance to nearest: Well Foundation - Property Line a DISPOSAL PONDS Cl 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 I/III 1 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, 1 shall not k 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: "1 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-must call for al3reqaad inspections. Complete drawing on reverse side. SignedX Title: _ Date: V f e FOR DEPARTMENT USE ONLY Application Accepted by Date '—:;I--' Area Pit or Grout Inspection by Date Fina Inspection by -� Date Additional Comments: r`3 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Yiracy 1335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNTGREMITTED CASH CK V RECEIVED BY DATE PERMIT'NO. ♦ EH13-24IREV.1/n5] �� 3�s G jr EH 128 4- - 1� I TL! J 00