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APPLICATION FOR PERMIT Es SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA N '� olw- Telephone (209) 466-67814L " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , , �t (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 Ryles and Regulations of the San Joaquin Local Health District. L, Job Address 3 Z W�Z,4 City 5 Tj{At- Lot Size PM Owner's Name 00195- �.�Gr.®/L �.L� cTdress ? !,�X ��L�dCsD Phone 4 O Contractor V ftA_*ddress icense No. Phone Gia TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS IQN SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ❑ Public ❑ Other ❑ Delta' Depth of Grout Seal Type of Grout ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane Type of Pump WIR. State Work Done Well Destr n ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 Y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION fNo 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 X 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 ❑ 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." 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 applicant must call for all required ins ctions. Complete drawing on reverse side. p Signed X__,07 Title: Date: 1�O FOR ENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by C Date*0,7Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 CAST{ RECEIVED BY DATE PERMIT"NO. + EH 13-24{REV.t/a5) 4" eno EH 14-26