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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� IJell 1601 E. HAZEL T ON AVE., STOCKTON, CA 1V 0 P JS Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �Q7 (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 Address City ��eAlLot Size PM Owner's Name �� S�� eE'iJ Address o�7��7" P��C �tPhone �,l� 1 Contractor FI-0yD W OG'� Address 7 X1, i�EG��7`_ License No. '�`Y�Y7G Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE LINES SAL FLD. PROP. LINE FOUNDATION AGRICUL URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ,PROBLEM AREA. RUCTION.-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. f Well Excavation * Dia. of Well Casing ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o asing Specifications (`I Public f) Other ❑ a Depth of G t Seal Type of Grout _ I I Irrigation --Approx. Depth I Eastern Surface Seal Ins ed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop Depth Filler Material [Bel, ) TYPE OF SEPTIC WORK: NEW INSTALLATION 11_ REPAIR/ADDITION D TRUCTION (No eptic system permitted if public sewer is ilable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms T r VZS 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 5 LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that f 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. 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 for all required inspections. Complete drawing on reverse side. Signed X_G � Title: Date: DEPARTMENT USE ONLY `� Application Accepted byL Date 5 °�� Area Pit or Grout Inspection by Date Final Inspection by A JA Date 3 Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24{REV.i/e 51 EH 14-28 i_25.00 3S