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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 Sari Joaquin Local Health District. Job Address J 7 City Lot Size > 100 PM IIS. `�r" Owner's Name Address Phone ii! Contractor — �� Address License No. Phone rte - TYPE OF WELL/PUMP: lil NEW WELL El WELL REPLACEMENT LJ DESTRUCTION ❑ i PU P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS dh INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Boitom. ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"1 Public L7 Other ❑ Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation A-Approx. Depth I 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 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION)K INo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence— Commercial_ Other 5 Number of living units: V Number of bedrooms r. y Character of soil to a depth11of 3 feet: Water table depth SEPTICTANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal . 'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 'No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property line SEEPAGE PITS 1 I :Depth Size Number !l SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .I�. I hereby certify that I have prepared this application and that the work will be done in accordance with Sari"Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§ttict. Home owner or licensed agents 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." II The applicant must call for all;required inspections. Complete drawing on reverse side. Signed X _ Title: .9%444*—& Date: �h ICI.I FOR DEPARTMENT USE ONLY q 1� f ! Application Accepted b Date Lie Area 2- 1II Pit or Grout Inspection by IIF Date Final Inspection by-5, ,�SA�(//-� _ Dated r _ _ Additional Comments: if y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies llp: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 ` INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE �7.P�ERMITNO. + EH 13-24 EH 14.24{HEV.I/n 5) Sls Q