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4 APPLICATION FOR PERMIT 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. �f Job Address % " / �__� _r City Lot Size PM 7 17 Owner's Name IZ_e_ ress P h o n Contractor s iVo, �" hon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications * Public f] Other Cl Delta Depth of Grout Seal Type of Grout I Irrigation --Approx. Depth l I Eastern Surface'Seal Installed by _ Repair Work Done- ❑ -Type of Pump H.P. State Work Done_ Well Destruction ❑ "Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 S7 TYPE OF SEPTIC WORK: NEW INSTALLATION 1r REPAIR/ADDITION l I DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.] f1 Installation will serve: Residence Commercial_ Other Number of living units: _ Number of bedroom Character of soil to a depth of 3 feet: Water table depth 44 SEPTIC TANK r ❑ Type/Mfg Capacity No. Compartments n PKG. TREATMENT PLT. ❑ f Method of Di osal k Distance to nearest: Wel! -..F Foundation _ _.__. Property Line * f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well _ Foundation Property Line _ SEEPAGE PITS 1 1 DepthNumber MP Ll Distance to nearest: Well 1 Foundation Property Line 'illiPOSALPONDS ❑ f a 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. t 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-conlracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant . t or all requi ed ns ctions. Comple drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 7 2$�/�' Area ` t Pit or Grout Inspection by Date--� Final Inspection by Date / 8� k I Additional Comments: _ ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 835-6385 s Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i I INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. I + EH 13-24(REV.1/"51 EH 14-28 `O