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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. 1662 for wefl/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address t� Pif' City .� "`- Lot Size PM Owner's Name Address /� J� Phone Contractor V -�/` r Address DJ (�(�Gt• License No. Phone TPJs WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE P AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom teca 'a. of Well Excavation Dia. of Well Casing } ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Se Type of Grout f �� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by V� Repair Work Done 110 Type of Pump H.P. State Work Done 0 Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 q OC TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) r 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/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 SEEPAGE PITS ❑ Depth Size Number SUMPS ElDistance to nearest: Well Foundation Property Line DISPOSAL 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 applicant us call for all req fired inspections. Complete drawing onrse side. Signed Sif1 J�/� rte` � Title: Data: �S FOR DEPARTMENT USE ONLY _Z S�.� Application Accepted by U` Date Area Pit or Grout Inspection by Date Final Inspection by Date 2 ✓ Additional Comments: ❑ Stk. 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. + EH 13-24{REV.rias) EH 14-28 S . 4=54:> Ko 10