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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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. may ", _, Job Address L? City' ► 14-, Lot Size PM r f Owner's Name r Phone �_2 Q 1777 AMEContractor ress License N hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O ER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FL PROP. LINE FDUNDATlON AGRICULTURE WELL OTHER LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CON STR ! IACATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ Casing Specifications ❑ Public ❑ Other n Delta epth of Grout Seal Type of Grout -- S I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _Jk, Number of living units: Number of bedrooms 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 i SEEPAGE PITS I I Depth Size Number SUMPS D 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 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 applic m t call for required inspections. Complete drawin r�side. Signed Titt [� < date: { 0 FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area / q Pit or Grout Inspection b Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 INFO jAMOUNT DUE AMD T REMITTED I 4r:CK RECEIVED BY DATE pPERMITNO. + EH 1 -241REV. /KS) T 7 C7�Q � --" ZZ -7 6 3Sse EH 114-28 J--� // L ! C