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i APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 fora permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.548 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 PM ddress Phor& S� F� � Owner's Name f �� ` License Ph9+fe Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION Sl ATIONS ❑ Industrial ❑ Open Bottom LI Manteca Dia. of xcavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications F] Public n Other ❑ Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. l I Eastern Surface Seal Installed by Repair Work Done ❑ T Pump H,P. State Work Done Well Destruction Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.l 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 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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." Contractors 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 appiic must call for all re red inspections. Complete drawing on side. 06—Signed Title: i��reve Date: ^Z FOR DEPARTMENT USE ONLY Application Accepted by '� Date Z Area Pit or Grout Inspection by Date Final Inspection by Date - �p Additional Comments: " f ❑ Stk 466-6791 Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 r� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13-241RINFO EV. 3v' 0-0 46 2' cD- EH 14-28