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APPLICATION FOR PERMIT i T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. ` Joh Address r City g'p P44m62=*_ Lot Size PM Owner's NameS!4zQ7 e Address ;fir '.S�__ _G -� Phone - Contractor # Address License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG CULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications fl Public C] Other Cl Delta Dep of Grout Seal Type of Grout I I Irrigation ___Approxi Depth I 1 Eas/ rn Surface Seal Installed by Repair Work Done ❑ 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 I 1 REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Nurnber of bedrooms i Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ _I_ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Leh gth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS FI 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 j 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 compansa- I tion laws of California.' The 7PIPx"" t must catl f �rquirecl inspections. Completd-drawing on reverse side. ��-� X 'Sign � Title: Date: — //� FOR DEPARTMENT USE ONLY Application Y b Accepted Pate 1 ` Area \.! P Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: t s- 1111 ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant - Return all copies to: Envirorimantal Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. INFO /� + EH 1 3-241REV.I/x51 -` r . EH 14-26