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�j APPLICATION FOR PERMIT .P, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r. (Complete in Triplicate) :1 ' I 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 Fmade in compliance with San Joaquin Count*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 Lot Size PM Owner's Nam Address Al,�, ( .l� Phone 9 2a-2 1 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P INE FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE WELL PROBLEM AREA CONSTRUCTION SPECIFIC S ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excav Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, Type o mg * Specifications LJ Public r ❑-Other '❑ Delta f Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth stern Surface Seal by Repair Work Done ❑ T mp H.P. State one Well Destructio ❑ Well Diameter Sealing Material (top 60') Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms y j 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 `'.❑ Depth Size Number 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 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 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 of California." The applicant IIfor all required inspectio Complete drawing on rLWersesiidee.. /f�J Signe Title: 41" " /W�-- Date: FOR DEPARTMENT USE ONLY E Application Accepted by Date � Area Pit or Grout Inspection byAld- Datep Final Inspection by Date G / Additional Comments: ❑ 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.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATEyyy PERMIT'N + EH 13-24(REV.i/w 57 # EH 14-26 cJ� ��/ ,�T """ J