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.; E-4 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address !/ u LL �I ity 1S10`' _ t Size PM // Owner's Name �f/Cr �'�/' r Address Phone ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _'SEWER LINES FLD. PROP. LINE FOUNDATION AGRICUL LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P MAR LL SPECIFICATIONS ❑ industrial ❑ Open Botto ❑ Manteca Dia. o ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ G Pack ❑ Tracy Type of Casin Specifications j hl Public Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation w..Approx. Depth I I Eastern Surface Seal Installed by Repair Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION l I DESTRUCTION {No septic system permitted if public sewer is C ? available within 200 feet.) Installation will serve: Residence— Commercial� Other - Number of living units: Number of bedrooms 1J\ 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 i LEACHING LINE ❑ No. & Length of lines Total length/size C� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ 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 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." Nsigned The applicant must call for all required inspections. Complete drawing on reverse side. X Title: Date: FOR DEPARTMENT USE ONLY l Application Accepted byDate ~ Area 0 s Pit or Grout Inspection by 12Date Final Inspection by Date Additional Comments: ta ❑ Stk 466-6781 ❑ Lodi 3(M-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ; INFO AM/O]UNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMI7'NO. +.EH 14-24 I REV.I/N 51 EH 91-28