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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT NO� � 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 V,)o 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. ti Job Address City Lot Size PM y( Owner's Named Address vp Phone Contractor 5n.0 Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTUR WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ,CON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- Excavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy "t- ,_ e T of Casin Specifications i'1 Public f=] Other Fl Delta Depth of Grout S Type of Grout I 1 Irrigation —.-Approx. Depth t I Eastern Surface Serif Instalie - Repair Work Done ❑ Type of Pump St a Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth -Filler'Material {Below 501 I TYPE OF SEPTIC WORK: NEW-INSTALLATION I:] REPAIR/ADDITION Ll DESTRUCTIO I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Reside nca— Commercial_ Other { Number of living units: 1 Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT. ❑ Method of Disposal �3 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 t T SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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. e. 7 Home owner or licensed agent's signature certifies the following: "I certify that in the.perfotmance 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 for ail required inspections. Complete drawing on reverse side. �f Signed X f Title: d r/ Date:ZAIC OR DEPARTMENT USE ONLY Q� "� Application Accepted by Date �r�1~ v / Area �S Pit or Grout Inspection by Date Final Inspection byr Date Additional Comments: � r0J G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITINO. EH 13-244REV.irn51 �� EH 14-26 `+�.J a z) v�