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.a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Address 7`ya i°` G�i '//Z City 7�C Lot Size PM Owner's Name es%,, ��l Address �� S ��'J ,(7A4/fid Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 TY PROBLEM AREA CONSTRUCTION . ❑ Industrial ❑ Open Bottom ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave ❑ Tracy asing Specifications FI Public - Other F Delta Depth of Grout Type of Grout f I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 Rf'PAIWADDITION f I 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line r LEACHING LINE ❑ No. & Length of lines Total length/size , 1 FILTER BED ❑ Distance to nearest: Well Foundation's� Property Line E SEEPAGE PITS ( I Depth -Size i Number SUMPS Ll Distance to nearest: Well Foundation " Property Line DISPOSAL PONDS ❑ 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not I 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 Cali rnia." The ap Iicant m st call for aalllllrr`equire i s. Complete drawing on reverse side. Signe vz- Title: Date: FOR DEPARTMENT USE ONLY I Application Accepted by bate — Area Pit or Grout Inspection by Date Final Inspection by IaL Date ! As Additional Comments: oC -� ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 $ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeEto Ave., P 0. B 2009,xr1}Stk., CAFEE 875201 ` T INFO AMOUNT DUE AMOUNT REMETTED CASH RECEIVED BY DATE PERMIVNO. p4 ♦.EH 13-21[REV,1/x 51 EH 14-26 L