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APPLICATION FOR PERMIT SAN JOAQUII LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone,(209) 466-6781 PERMIT EXOiRES 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 "' ' c�" Cit V64i Lot Size PM 1J kOwner's Name AddressPhone Contractor ` L ■N Address 2q�`'f Ql' � License No. 7/61A Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO 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 SPECIFIC TI ! ' ❑ In C]O ottom 1-1 Manteca Dia. of Wel! Excavation Dia. of Well Casin omestic/Private Gravel Pack: C7 Tracy Type of Casing Specifications f'1 Public F Other Ll Delta Depth of Grout Seal 7pe of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed,by V It VA-4 Repair Work Done ❑ Type of Pump H.P: State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 6� Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I ) INo 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 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size' Number SUMPS C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict- 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 l 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 applicaA t If r r din ctio s. Complete drawing on r � e std Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b, Date 3� Area Pit or Grout Inspection by Date jl. Final Inspection by Date { Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE . AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH ♦.EH 13-24(REV.I i e 51 EH 14-26 v D