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Cf APPLICATION FOR PERMIT EQ, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA IIA i �. Telephone-(209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in rTriplicate) � . 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 �Jk4- City Lot Size PM ` �j r Owner's Name JA PRe Address !Q ' ( r / C�a Phone Contractor Address /` 5 r License No Phone ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE • i FOUNDATION AGRICULTURE WELL .OT L PITS/SUMPS �,,, h INTENDED USE TYPE OF WELL PROBLEM AREA CONS ON SPECIFICATIONS - � 1 ❑ Industrial ❑ Open Bottom r C1 Manteca ia. of Well Excavation Dia. of Well Casing ❑ DomesticlPrivate El Gravel Pack acy Type of Casing Specifications — Fl Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout v I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by - Repair Work Done Type of Pump H.P. State Work.Done Well Des on ❑ Well Diameter Sealing Material itop 50') Depth Filler Material IBelow 50'1 AVk TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION/IN (No septic system permitted if.puhlic 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line `p DISPOSAL PONDS ❑ i 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 i 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 must call fo if r uir inspections. Complete drawing on reverse side. igned X S�DR DEPARTMENT USE ONLY Y Application Accepted by qmLo� DateA � � Area Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ' ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 VV ,Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 !�7' FEE AMOUNT DUE AMOUNT REMITTED CK CASK RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 1REV.i/n sl V C, EH 14-29 ~J