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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address _ ai 3 City G Lot Size PM Owner's Name M s L L Address Phone Contract' Address License No.-; ��1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ;QTHER 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 ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') w I Depth Filler Material {Below 50') UJ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONt% DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence 14!005"Commercial_ Other -. Number of'living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 141 SEPTIC TANK *q Type/Mfg L Capacity�� No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal` 1 Distance to nearest: Well Foundation 30 Property Line LEACHING LINE ❑ No. & Length of lines R (b g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property 6ine D { SEEPAGE PITS ❑ Depth Size Number — - SUMPS ❑ Distance to nearest: ,WellFoundation Property Line DISPOSAL PONDS ❑ y hereby certify that I have prepared this application'find that the-work will be done in accordance with San Joaquin coun ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. .> Homeowner or licensed agent's signature certifies the follop' t, .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 t�d"''workman's compensation laws of California." Contractoes hiringor sub-contracting signature certifies the following:"I certify that in the performance of the work fog which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. 1 J The applicant must call for re u' d inspectiowAComplete drawing on reverse side. ; Signed Title: Date: / J FOR DEPARTMENT USE ONLY Application Accepted by ° 1 Date. Area 49 Pit or Grout Inspection by Dat Fin Inspection by Date p`+� Additional Comments: ? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-SM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201: t FECK E INFO -_AMOUNT DUE .AMOUNT REMITTED CASH RECEIVED BY DATE'\ PERMIT'NO. :. t EH13-24(REV. - - 4 EH 14-26 CA, i CY Cy S-I