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APPLICATION FOR PERMIT 1 ; J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �i 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 Zx�U PM Owner's Name ddress Phone Z, -/ Contractor Address License I Phone TYPE OF WELLIPUMP: U NEW WELL ❑ WELL REPLACEMENT ❑ DE RUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work D 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 fl REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i� 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 SEPTIC TANK Type/Mfgj 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 SEEPAGE PITS ❑. Depth Size Number t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared thisapplication 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.. i 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." II j The applicant mu II for all required inspections. Complete drawing on reverse side. r XSigned Title:_ � Date: V---,22 !E�'_ 9 r �.xJw•+rr2..� �� FOR DEPARTMENT USE ONLY _ Application Accepted by \711U1�K... Data Area Pit or Grout tris �" �� pection Date - Final,.Inspection by Date _ Additional Comments; ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 cl pel�L(f�p Applicant- Return all copies to: Eny'ronmental Health Permit Services 1 1 E. azelt n Av O. Z Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. QMED + EH 13-24(REV.1 i 9 s) ^j{ IJ PITEH 14-26 N Is C.