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APPLICATION FOR PERMIT N a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED rys-�aa� S (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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address j am!! City 9A'r 1�OT Lot Size PM Owner's Name Address ` Phone Contractor Address �� 1''a✓ /%0/dA License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRIC RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO) AR CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom Manteca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Ca i Specifications 171 Public Ci Other F1 Delta Depth of Grout al Type of Grout 1 1 Irrigation —_Appy 11 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION (No 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 eine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Pfoperty'Line SEEPAGE PITS I 1 Depth Size Number 1_ SUMPS Ll Distance to nearest: Well Foundation Property Line S DISPOSAL PONDS ❑ I hereby certify that I have,prepared this application and that-the work will be done i_n accordance with San Joaquin county ordinances, state laws, and %P rules and regulations of the Sari-JdaquinLocal Health District.• } Horne 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 must call for eq u d inspections. Complete drawing on reverse side. Age Signed X Title: Date: FORAOT T USE ONLY ) Application Accepted by Date '��C_JJ Area Pit or Grout Inspection by Date Final Inspection by r/6 ✓ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi/-36-9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAS 95201 w FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO + 11in r.EH13-24(REV.1)1451 ". ---'��.. � :35.t1U + 3► � V S VLJ '/6�� EH 14-28