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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 tY � pD /r d City �Lot Size PM Owner's Name �/�© 5' /1rQ4cidress Phone Contractor hO,To Tdw• kXAddress'p, > License Na Phone Ta�, 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 PIT /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ion pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracya of Casing Specifications (`l Public 1-1 Other Depth of Grout Seal Type of Grout _ I I irrigation _..Appro t { I Eastern Surface Seal Installed by _ Repair Work Done ❑ of Pump H.P. State Work Done Well Destruc' ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION I I DESTRUCTIONI (No septic systern permitted if public sewer is Wv 'I�lable vyii in 200 feet Installation will serve:, Residence_ Commercial Other Q��r'(J�7fY/ �e Number of living units: Number of bedrooms /�� Character of soil to a depth of 3 feet: Water table epth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q 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 I I Depth Size _ Number SUMPS L.l 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 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." Contractoes 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 applic ni mu coq for all required in pe s. Complete drawing on reverse side. J Signe Title: Date:'+_ FOR DEPARTMENT USE JLY (� Application Accepted by Date " {' Area 11 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. ♦ EH1 3-24{REV.I/H 5) EH 14-28 / `