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APPLICATION FOR PERMIT SAN ,fOAOUIN LOCAL HEALTH A. 9 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �. (Complete in Triplicate) ��1Ro�M s'e ppit Application y 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. 0157_ OW 3 - / Job Address City ,9 Lot Size PM Owner's Name Address �� ootk t oc'� Phone 3 Contractor Address Lu &e1A0Ag 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 PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {` ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation -Dia. of Well Casing ^©F� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications wpublic F1 Other F Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx, De th I I Eastern Surface Seal Installed by _ i`", Repair Work Done ❑ Type of Pump 0J ej H.P. IS State Work one Well Destruction ❑ Well Diameter _ � Sealing Material (top 50') Depth f Filler Material (Below 50'1 f� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIR/ADDITION I ! DESTRUCTION I I INo septic system permitted if public sewer is I 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 v ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal " Distance to nearest:. Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ii Depth Size Number 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 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 fol) f g: "1 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 Ca nia." The applic t t call for all req d inspe 'ons.,rYoinplete drawing on ev rs side. Signed X Title: o Date: _ OR DEPARTM T USE ONLY Application Accepted by DateArea .2/3 Pit or Grout Inspection by Date '3iFinal Inspection by�IV Date�3 V 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.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH1 3-241REV,t/A51 '35 _ 1�..'}�8� �� EH 14-211 - P