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R __ APPLICATION FOR PERMIT � " C o* ..,,. s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. ,(j. Job Address -L� L'c-)dam City �/A"' ��Lot Size PM +� Owner's Name Address Phone Contractor Address License No. Phone ��i3� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICU3tTE HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROSLE REION ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaE avation Dia: of Well Casing ` Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyg p FI Public Cl Other ❑ Delta ut Seal Type of Grout I I Irrigation Approx. Depth I ) Easterninstalled by - Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealin aterial (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t 1 DESTRUCTION No septic system permitted if public sewer is a ailable 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 I I Depth Size Number SUMPS {_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LJ 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." The applicant m st-call for all required inspect_I ns. Complete drawing on reverse side. Signed X z�`�-- Title: Date: �6 FOR DEP TMENT USE ONLY Application Accepted by jDate y� —97 f Area Pit or Grout Inspection by Date Final Inspect( n by &:yw& Additional Comments: ��J yp2 t euros d 62` ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'e 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 ASH RECEIVED BY DATE PERMIT'NO. INFO upy�/� + EH 13241REV.iin51 � 9—/ l[ EH 14-26