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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT Io k 1601-E. HAZELTON AVE., STOCKTON, CA iY+a Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 < City Lot Size PM � A' Owner's Name ress 4Z Phone Contractor Address License No. Phone TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC T SEWER LINES DISPOSAL FLO. FOUNDATION AGRICULT R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECI S El Ll Open Bottom anteca Dia. of Well Excavation of Well Casing ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing Specifica i ❑ Public er ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by e Repair W one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION V(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 Isr Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest: Well Foundation Property Line p" LEACHING LINES ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line v - ' SEEPAGE PITS ❑ Depth Size-. Number SUMPS ❑ Distance to nearest: Well Foundation Property Line c DISPOSAL PONDS ❑ F 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 must call foVII required inspections. C I drawing on reverse side. ` - Signed-X i./1n n/►.L_fl�..� � � Title:, Date: - FOR DEPARTMENT USE ONLY Application Accepted by Date LArea i Pit or Grout Inspection by Date Final Inspection by Dat LZQt Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 + FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''N0. INFO CASH / f' + EH 4324{REV. /e s} a�� J� ! V-14—� I le r7- EH 14-28 Y