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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Wit Ute~ ' 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address `I S " > l $ Cit Lot Sized ?c PM Owner's Name 7' ddress lTl s �i t:b�p Phone Contractor Address - License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- _SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL 0 ELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Trac Type of Casing Specifications { f 1 Public F1 Other elta`, Depth of-'Grout Seal Type of Grout _. ; I I Irrigation __A epth I I Eastern Surface Seal Installed by _ Repair Work Done pe of Pump H.P. State Work Done Well Destr ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) �: 1 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 i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line " LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; �x SEEPAGE PITS JI Depth Size _ Number s SUMPS L] Distance to nearest: Well Foundation-. --:_Property-YLine' l E DISPOSAL PONDS ❑ f - 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." } T lica. must call for all require -nspec ns. Complete drawing on reverse side. Signed X `Title: Date:,:--- p F DEPARTMENT,USE ONLY Application ccepted by ..A'tt& Date Area - Pit or Grout nspection by Date _ Final Inspection by Date/ Additional Comments: I�' ��L l 1-J ❑ Stk 466-3781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 835-6385 "`-Applicant eturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT-NO. INFO n . EH 13-24(REV.ties) c ac) x/--29 7 EH 14-26