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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED fi (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 xCityLot Size Owner's Name r4 / dress � Q•='.. `� Phone 6 i Contractor ddressI Je�i"ense No� I P e TYPE OF WELL/PU P: NEW ELL ❑ WELL REPLACEMEN—T-71 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �O7 Q ' DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD .PROP. LINE FOUNDATION AGRICULTURE WELL QTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. o xcavatlon Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing iSpecifications ❑ Public ❑ Other a Depth of Grout Seal Type of Grout E3 Irrigation . Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. E State Work Done ` Well De ion ❑ Well Diameter Sealing Material (top 501 Depth Flier Material (Below 50') # TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic'system Oermitted.if public sewer is available within 200 fee#.1 Installation will'serve: Residence_ Commercial Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth 4 ++ SEPTIC TANK ❑ Type/Mfg Capacity a No. Compartments ` I PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest: Well Foundation Property-Liine LEACHING LINE ❑ r No. & Length of limes ..` Total length/size } f _N FILTER BED ❑ Distance to nearest:, Well Foundation Property Line SEEPAGE PITS ❑ Depth` Size Number SUMPS ❑ Distance to nearest: Well t 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 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 cal all uir 'ns ctions. Comp drawin arse side. Signed Till .� Date: �Q FOR DEPARTMENT USE ONLY Application Accepted by ' ✓✓ �� Date 3^ Are 0 I Pit or Grout Inspection by Date Final Inspection by Date i ' i Additional Comments: GAJ ❑ 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 1 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH f428(REV.1/a 5Y .t �,! u 3"�' Y7 ?-7 S l