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APPLICATION FOR PERMIT �.- SAN JOAQUIN LOCAL HEALTH DISTRICT n 1601 E. HAZEL T ON AVE., STOCKTON, CA 5L 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 sowage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /� J ,q, Job Address . r� G " 1^ -._ Citv,,® � Tom!V Lot Size PM Owner's Name 7 Address Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r7 DESTRUCTION ❑ PUMP ALLATIO-N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE A; FOUNDATION AGRIC OTHER WELL PITS/SUMPS INTENDED USE >Gravel LL PROH EA CONSTRUGTI CIFICATIONS ❑ Industrial Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Tracy Type of Casing ecificationsf l Public 171 Delta Depth of Grout Seal Type o t _. I I Irrigation —.Approx. Depth I I Eastern— Surface Seal Installed by _ Repair Work Done LJ Type of Pump P iii State Work Done Well Destruction ❑ Well Diameter x Sling Material stop 501) Depth x Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION INo 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/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 11 Depth Size Number SUMPS L71 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, slate 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 Californi ."Contractors 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 must call for all required inspections. Complete drawing on rev rse side. - Signed XZ,--Y ,r—t- It'ra6t Title: Date: A FOR DEPARTMENT USE ONLY Application Accepted by L& Date Area 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ too—nf' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT D AMOUNT REMITTED CK H RECEIVED BY p1DATE PERMIT'NO. + EH 1 -24IREV.tiksl �S� �V t� [2Z�( ( lei y �� EM 4