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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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.. `'�'''I,, Job Address + l �! Gj ppj- City Lot Size PM r r Owner's Name Q Address / d �� Phone Contractor Address- � _f� /]- /��j se No." Phone_ TYPE OF WELL./PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO �I-- P P'INSTALLATION [D " SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI [IyK SEWER LINES POSAL FLD. PROP. LINE FDUNDATION AGRICULTURE.U1,Et f OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEMCONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom nteca Dia. o cavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack { ❑ Tracy Type of Casing Specifications ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout r , ❑ Irrigation �Approx. Depth , ❑ Eastern Surface Seal Installed by v , Repair Work Do ❑ Type of Pump H.P. State Work Done Well pestru Fon ❑ Well Diameters Sealing Material (top 50') r Depth i Filler Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is v► Installation will serve: Residence— Commercial i available within 200 feet.) Other to Number of living units: Number of bedrooms 3 Character of soil to a depth of,3 feet: kWater table depth SEPTIC TANK ❑ Type/Mfg �� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property ILine t I LEACHING LINE ❑ No. & Length of lines iTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line —SEEPAGE PITS ❑ •-Depth Number SUMPS ❑ Distance to nearest: Well Foundation y 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 f " employ any person in such manner as to become subject.to workman's compensation laws of California.;' Contractor's hiring or sub-contracting signature tioncert'fies the laws offCaliforna. ••I certify that in the performance othaw`!for which this permit i issued,l shall employ.persdns subject to workman's compensa- The app i t must call for all required in ns- Com�pplete drawing on reverse side. Sig?dX Title Date: FOR DEPARTMENT USE ONLY AppAccepted by DateArea Pit Inspection by Date Final Inspection by zlotc� Date 2 3 7 Additional Comments: e C `rZ, ❑ Stk 466-6761 ❑ 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, Silk., CA 95201 FEE AMOUNT DUE AMOUNT CK INFO REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.ties] -��[} C^-- EH 1428