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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 cal Health District. qj g Job Address '03 J ��'� + l/�� City Lot Size °a- PM Owner's Name Oz 1]1f L [] Address YY1YZ_ Phone . Con r a c t o r Address , , License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCT SPECIFICATIONS ❑ Industrial F) Open Bottom ❑ Manteca is of I Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing Specifications F1 Public ❑ Other ❑ Delta Depth Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I 1 Eas Surface Sea stalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION l I DESTRUCTIO iNo septic system permitted if public sewer is V� 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/Mfg Capacity----------:- -No.-.Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (`47 V I LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ 1 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 applican u t all f all quired i coons. �pmplte drawing on reverse side. Signed X Title: Date: EP*RTONLY ' r Application Acc?ents: d b Date Area Q� Pit or Grout Inson to Fin action by Date ' t Additional Com ILP ❑ Stk 466-6781 0 Lodi 369-3621 0 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 AMOUNT/D�U.EE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. +.EH 14-29(REV.t i x sf 35 . V L ` Q {� '�-b ��3.{`