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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT cc 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 City Lot Size PM Owner's Name L T5 L G a CY—V Z—Address Phone ~` Contractor �� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK E__��AG�RQRE WNES DISPOSAL FLD. PROP. LINE r FOUNDATION WELL OT LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ON SPECIFICATIONS V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc tion Dia. of Well Casing ❑ Domestic/ ❑ Gravel Pack y Type of Specifications Casing— ['I Public Ll Other n Delta Depth of Grout Seal Type of Grout _. I I Irrigation fox. Depth € I Eastern Surface Seal Installed by Repair Work Done 0 ype of Pump H,P. State Work Done_ Well Destructio ❑ Weil Diameter Sealing Material {top 501 Depth Filler Material (Below 50') _ �1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I INo septic system permitted if public sewer is � ' 1 available within 200 feet.) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: -Well Foundation Property Line 5 LEACHING LINE ❑ No. & Length of lines ..,Total length/size FILTER BED ❑ Distance to nearest:_ ' 'Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl Distance to nearest: WellFoundationµ "Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be'dorie-in accordance with San Joaquin 2county 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 laves of California." Contractor's hiring or sub-contracting signature certifies the follow' g: "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 Cal'or ia." �. The applicant u call f 11 require inspections. Complete drawing on re rse sides Signed le:_�k G _- -- Date: OR DEPARTMENT USE ONLY Application Accepted by Date 3 _g Sao Pit or Grout Inspection by Date Final Inspection by `- Date Additional Comments O� �rt�� 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca /823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE INFO �r7� CASH /y aPERMITNO. +.EH 13-24 IAEv.v i n 51 Sr�� v,� EH 14-28 1