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APPLICATION FOR PERMIT K� - SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZE 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. I A Job Address /Id �/f.. Cit Lot Size PM I Owner's Name ` Address Ph tom`''/ • 1 ' // w, 1 ift Contracto Address 136 -L°_Licens c1Y Ph re `��1a/ TYPE ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ICATIONS I C] Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other elta Depth of Grout Seal Type of Grout 11 Irrigation _A Depth 11 Eastern Surface Seal Installed by Re air Work Done ' p ype of Pump H.P. State_Work Done_ Well Des n ❑ Well Diameter Sealing Material ftop 501 �? Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRYADDITION I ) DESTRUCTIO INo septic system permitted if public sewer is i vailable within 200.feet.l — �, I Installation will serve: Residence Commercial Other I 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. ❑ � I Method of Disposal ; Distance to nearest: Well Foundation Property Line 1 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 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 applicant st callfor all require spections. Complete drawing on re rse side. I Signe /G - Title: Date: F DEPARTMENT USE ONLY Application Accepted by k Date ' Area Pit or Grout Inspection b p y Data Final Inspection by �- (T" Date Additional Comments: —7 '} ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services J ervices 1607 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMI7'NO. l INFO +.EH 13-24 IREV.t/H 5) 9� '� ',' -26 EH 14 L