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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 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. Job Address �" "' City `� Lot Size-,SOXPM Owner's Name ..�`�� v" odress �� Phone Lk Contractor Address 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 ITS/SUMPS INTENDED USE TYPE OF WELL PROBIEM AREA TIONS ❑ Industrial El Open Bottom El Ma Dia. of Well Excavation ell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications" ❑ Public r ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth i 1 Eastern Surface Seal Installed by - Rtp�l ork Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR)ADDITION ( I DESTRUCTIO 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 SEPTI C'TA ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT Method of Disposal Dista Barest: Well Foundation Pr LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nares alt Foundation Property Line SEEPAGE PITSepth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DI AL PONDS ❑ 1 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 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 app ust cal for aN requir�d inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Area�r Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date - 0 44 7 Additional Comments: A"a 7 e e 6- � .f - ❑ Lodi 369-3 ❑ Manteca 623-7104 ❑ Tracy 835-6385 � ❑ Stk 4fi6 fi781 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA M01 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13.241REV.1/R51 EH t4-26 O