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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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. / GI p Cp / Job Address /777 !t d___o ta7 i_�r' ,,Q�d'-C._ _ _ City jt/I�gr Lot Size e w PM r f Owner's NameDO i.., A19 s_ _Address Phone Contraclot _ _ _Address_ B r License No.47 66L—Phone 0 TYPE OF WELL/PUMP: VNEW WELL ❑ T WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA14.ON 0 s SYSTEM REPAIR ❑' - OTHER-E]— DISTANCE TO NEAREST: SEPTIC TANK SEWERLINES DIS AL FLD. PROP. LINE FOUNDATION GRICULTURE WELL THER WELL PITS/SUMPS _ I` INTENDED USE- TYPE OF WELL PROBLEM'A CONST ION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private. ❑ Gravel-Pack ❑ Tracy Type o sing Specifications t"1 Public v ❑ Other ' ❑ pe Depth of Grou eal Type of Grout i I Irrigation _..Approx. Depth Eastern_ Surface Seal Installe y V Repair Work Done . Type of Pump '� H.P. State Work Done_ Well Destruction ❑ Well pia er Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [1 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 Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size 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, and r 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 r 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." i The applic t ust call foE all re uir d inSDBcti o Complete drawing on reverse side. Signed X w. Title: Date: �3 V FOR DEPARTMENT USE ONLY Application Accepted by Date 3T � Area Pit or Grout Inspection by Date Final Inspection by Il Date 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CfASH 'RECEIVED BY DATE PERMIT NO. +.EH1 3-241qEV.r/r35f EH 14-26