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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT i 1601 E. HAZE I 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. Job Address1Py City f ' Lot Size PM L 4. Owner's NamAddress,/L '1,1 fil, � _ Phone Contractor dress GJ icense No. 2_-Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout L�Irrigation —_Apprcx.-DeW_h_'�❑� astern Surface Seal Installed by O� -Repair Work-Done' C]��' Ty-p-&—of Purrtp H.P," 15 Slate Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/'ADDITION ❑ DESTRUCTION ❑ (No 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: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENTi PLT. ❑ _ ._ 4.-.� _ �_- ;.._.. _ ._.. _ _ r - Method of Disposal- 1 i Distance to nearest: Well i Foundation Property Line j i LEACHING LINE ❑ L No. & Length of lines a Total length/size � € FILTER BED ❑ Distance to nearest: Well t Foundation Property Line , SEEPAGE PITS ❑ •Depth Size Number SUMPS ❑ Distance to nearest: Well i Foundation Property Line DISPOSAL PONDS ❑ j 1 I hereby certify that I have prepared this application and that thej�vork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , f, Home owner or licensed agent's signature certifies the following: '1 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." 3 The applicant t cal or all quir mspecti S. Complete drab ing verse side. ?�f J Z. Signed /`Title: Date: FORD PARTMENT USE ONLY Application Accepted by '?PART Date Area ol Pit or Grout Inspection by Date I Final Inspection by Date ��6 0 1 Additional Comments: # 9/,/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% 11 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV EH 1126