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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 LI tp "` ' City'sLbt Size PM . Owner's Name F AddressP-' -- Phone Contractor Address License N d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PU P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0 DISTANCE TO NEAREST: SE K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL REA CONSTR PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca I Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications ❑ Public ❑ Other ❑ Delta— Depth-of-Grout-Seal' " "„ -Type of Grout ❑ Irrigation x. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ pe of Pump H.P. State Work Done Well Destruction - ❑ Well Diameter Sealing Material (top 501 1. Depth ' Filler Material (Below 501 t i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/'ADDITION ❑ DESTRUCTIONS(No septic system-permitted if public sewer is available within 200 feet.) { Installation will serve: Residence Commercial Other kk i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -r Water tabledepth 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 f SUMPS ❑ Distance to nearest: Well Foundation Property Line { I DISPOSAL PONDS ❑ L i 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 F rules and regulations of the San Joaquin Local Health District. I i 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-ihis'paimit•is issued);I shall employ persons subject to workman's compensa- tion laws of California." r- 1 k The applicant st call for all requir ns. Complete drawing on reverse s1dq, Signed Title: .Date: FOR DEPARTMENT USE ONLY Application Accepted by 'Date Area-7& �� # Pit or Grout Inspection by Date' Vlmal Inspection by T6&Z." Dai Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy' 8355-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. INFO CASH �� { r EH 13-241REV,i/65l � ,ate '� � Z"1 �-7 1L4 �- EH 14.26 "- i,5-1