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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 Rules and Regulations of the San Joaquin Local Health District. Job Address Z6 40 4 3 49�Lot Size PM Owner's Name Address Pho w Contrac ` Addres� 1� License f fZL. Phon� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Il PUMP INSTALLATION ❑ .SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ra. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications (l Public f] Other Delta Depth of Grout Seal Type of Grout _ I I Irrigation —._Approz pth I i Eastern Surface Seal'Installed by _ Repair Work Done ❑ Ty ump H.P.- ' " State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material i8elow 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION t I DESTRUCTION)eqNo septic system permitted if public sewer is available within 200 feeLi 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 ❑ No. & Length of lines _ _ ,TotalJength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size 7 Number SUMPS 0 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, anck 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 applicant ust call for all required ins tions. Complete drawing on revs side. Sig Title: 4rZ� Date: FOR DEPARTMENT USE ONLY y /1 Application Accepted by Date � 4 Area r J Pit or Grout Inspection bate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASCK H RECEIVED BY DATE PERMITT'yyyyNO. +.EH 13-24 IREV.t/h 5f EH 14-26