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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDe� � fJwv�d�, (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 City // Lot Size PM Owner's Name &L Address T� Hyl�J � Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUN ATI AGRICU URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 4F WE PROBLEM A A CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack Tra Type of Casing Specifications I") Public 11 Other n Ita Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth East Surface Seal Installed by (r, Repair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diamete Sealin aterial (top 50') �1 Depth Filler Maten Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i-I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial_ Other s j Number of living units: •' Number of bedrooms Character of soil to a depth of 3 feet:— Water table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal u Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'] Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS r C 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." The ap is nt must call for all requir d ' spections. Complete drawing on reverse side. r� X Signed Title: J Date: rpt I FOR DEPARTMENT USE ONLY L!� Application Accepted by Date v� Area a Pit or Grout Inspectio by Dated i Final Inspection b. Additional Comments: r�„V �r�f/ ❑ Sik 466-6781 Q Lodi 369-3621 ❑ 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 DUE AMOUNT REMITTED CASH RECEIVED BY PATE � T'NO,MI + EH 114 2e 3-24(REV EH r,, ' F t