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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 TYEAR 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•nccompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin [Job al Health District. Address Citq %� Lot Size PM ner's Name �r4Y` ti./t� ��r�/ Address ��✓ Phone tractor_ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA WER LINES DISPOSAL.FLLD..� mW LINE FOUNDATION AGRICULTUn�S�W�-- _ t�E Wfi ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE�MAREA—"'CONSTRUCTION SPECIFICATION - ❑ Industrial ❑ Open Bottomants teca Dia. of Well Excavation Dia. of ell-Casirig j ❑ Domestic/Private ❑ Grav ❑ Tracy Type of Casing Specifications ❑ Public Other C1 Delta Depth of Grout Seal Type of Grout I 1 Irriyatia pp air Depth I I Eastern Surface Seal Installed by air Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other I Number of living units: Number of bedrooms i 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 CJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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 taws 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 fora required inspections. Complete drawing on reverse side. �J Signed X ' Title: Date: Z/1— U FOR DEPARTMENT USE ONLY f r�n Application Accepted by Date TUI Area 'f Pit or Grout Inspectio b Date Final Inspection by Date L �i +7 f Additional Comments: r f ^- - e1� ❑ Stk 466-6781 i❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6U5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Sik., CA 95201 cRffQ�y/�. INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.t/K 5} .g 15 S 7 7 E H 14.28