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APPLICATION FOR PERMIT +� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. Thisepplication 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 AW M 4G 9 a VG vow Owner's Name Address �7 4 �- d. Phone Contractor Address 74 License NQ.- -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEWITILICTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---A Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ T of Pump H.P. State Work Done_ Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Wf DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) �• Installation will serve: Residence X Commercial_ Other Number of living units: Number of bedrooms_1r 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 le No. & Length of lines s Total length/size ;L FILTER BED ❑ Distance to nearest: Well_ Foundation—f�a / Property Line SEEPAGE PITS Depth 49 ZA Size Number SUMPS ❑ Distance to nearest: Well oundation Property Line DISPOSAL PONDS ❑ 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 applicant must II or all required inspe ' s. Complete drawing on reverse side. AA Signed Title: Date: v FOR DEPART NT USE ONLY Application Accepted by \(kl Date 1^ Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ 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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. +.EH 13.241REV.1/X5) EH 14-26 V `•+'iJ'