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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {208) 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 Ryles and Regulations of the San Joaquin Local Health District]] Job Address �1 L 1�X2ADGA;) L>4� - City �� Lot Size PM Owner's Name Address Phone c35*2 Z. R� 8 -sem Contracto -� Address Tj� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ "" DESTRUCTION ❑ i 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 Seal"_ Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastelp Surface Seal Installed by— Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -r Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION geiNo 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 2;---Type/Mfg Ab O A 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 ❑ - epth Size Number i Y SUMPS ❑ Distance to nearest: Well Foundation I Property Line DISPOSAL PONDS ❑ ; I 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed a ant'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 su manner as to become subject t workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:' certify that in the performanc a work for which this permit is issued, I shall employ persons subject to workman's corripensa- tion laws of Californ' .' The appli ant s callforall re late everoe9de. Sign �" Ti � Date: v F DEPARTMENT USE ONLY _Lf 5_ Application Accepted by �� Date Area i Pit or Grout Inspection by Date Final I pection by Date WNS V 011/ i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 rApplicant Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.Q. Box 2009, StC to 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT N0. INFO CASH 40 to + EH 13-24{REV.1/a 5) 4--__ 8J, EH 1426 r