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t APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 aCounOrdinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address jj City Lot Size PM Owner's Na dress f �7 S Phone Contractor Address License No. Phony TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA EPTIC TANK SEWER LINES DISPOSAL FLD. PRO FOUNDATION RE WELL OTH PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CTI ATIONS ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation ia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specificatio i FI Public ❑ ❑ Delta Depth of Grout Seal Type of Grout I Irrigation —.-Approx. Depth 11 Eastern Surface Seal Installed by Repair Work ❑ Type of Pump H.P, State Work Done Well uction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I (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 LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS I I Depth Size _ Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be rules and regulations of the San Joaquin Local Health District. done in accordance with San Joaquin county ordinances, state Paws, and 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 call for all uir ctio s. Complete drawing on reverse side. (� Signed X Title: Date: f�^ Z –� d FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Fin�Inspectionby �1-1 Date Additional Comments: �a�,V ❑ Stk 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 r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO H + EH 13-241HEY. EH 14-26