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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 I. 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. ` o Address t City of Size PM e e Address ph".-i rr?as Contractor Addre .. 5• LicerLgg, Veff P o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO !CATIONS ❑ Industrial ❑ Open Bottom • _ ❑ Manteca, D' - ell-Excavation, -.,__Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack 1 ❑ Trac _ Type of Casing Specifications I'] Public ❑ Other elta Depth of Grout Seal Type of Grout I I Irrigation _ Depth I 1 Eastern Surface Seal Installed by Repair LVork Done ype of Pump H.P.# Stale Work Done _ _ Well Destru r" ❑ Well Diameter i Sealing Material (top 50'1 f - + Depth =__E Filler Materiel{Below 501 PE OF-SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION i I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.I Installation will serve:-i"Residence Commercial— Other Number of living units: Number of bedrooms : Character of soil to a depth of 3 feet:' v " -A Water table depth SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ > �" _WtiJiod of Disposal Distance to nearest: iWell w • Foundation Property Line F LEACHING LINE ❑ No. & Length of lines ' ' ! TotaI16ngth/size t FILTER BED ❑ Distance to nearest.- ?Well -Y "` Foundation �'Property,Line Q . � t •-! 4 J . r e t SEEPAGE PITS 11 Depth f Size ^ Number SUMPS ❑ Distance to nearest: 'Well �- Foundation Property Line DISPOSAL PONDS ❑ I i I hereby certify that I have prepared this.'.application and that the work will be done in accordance with San.Ioaquin 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'performaiice of the work for which this permit is issues,vshill employ persons subject to workman's compensa- tion laws of California." t , The applicant m t call for all required inspections. Complete drawing on rev side. Signed X M Title: Date: � r T FOR DEPARTM T USE ONLY Application Accepted by Date as , Pit or Grout Inspection by to Final Inspection by Date Sr 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 r' FEE AMOUNT DUE AMOUNT REMITTED CK INFO GASH RECEIVED BY DATE PERMIT'NO. ]]]•�� + EH 13-24(REV.riM51 EH 11-28 `�