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APPLICATIONtFOR PERMIT + ' SAN JOAQUIN LOCAL HEALTH DISTRICT ►VO 1601 E. HAZELTON AVE., STOCKTON, CA N�� Telephone (209) 466-6781 PERMIT EXPIRES .1 YEAR FROWDATE 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 h City Lot Size PM Rfi�t1 D 0 // Owner's Name Address T� Contractor's Name 5 'icense No. T'�� _ Phone TYPE OF WELL/PUMP: NEW WEA ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seai Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ID Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') V ; ' Depth _ Filler Material Below 50'1 \ TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADD 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 Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg77_ Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Method of Disposal g 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 j SUMPS ❑ 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 Sari 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:,;;)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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must callF e airs spections. Complete drawing.o ewers�e side. !' ,, s� l I Signed Title: `7t�irGc��i Date:&Y, } FODEPARTMENT USE ONLY pp Application Accepted by IAJCC�� amC.rm..�_ Date a- —J Area / Pit or Grout Inspection by Date ' Final Inspection by Date Additional Comments: ❑ Stk -466.6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMO[U^NT DUE AMOUNT REMITTED CCAKSH RECEIVED BY ' DATE PERMIT"NO.' �. + EH 13-24(REV.10183) 3`� t d� - - Q-A;�-X 7 EH 1126 -