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APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) . I 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/ and the Rules and Regulations of the San Joaquin Local Health District. s Job Address _� � ''[`+`�'1� r City tLot Size PM Owner's Name �✓ �✓� 1�/�Xraddress '7D y G7 IC7 _ Phone G 13 3 5 J Contractor Address ' � License No. Phone TYPE OF WELL/PUMP: S, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPEC IONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well E ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type sing Specifications ❑ Public ❑ Other ❑ Delta epth of Gro Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal In d by Repair Work Done ❑ Type of Pump H. tate Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: --/— Number of bedrooms Character of soil to a depth of 3 feet: 4bo 13, Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments ja PKG. TREATMENT PLT. ❑ § Method of Disposal Distance to nearest: Well I 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 ❑ Distance to nearest: Well Foundation Property Line s , DISPOSAL PONDS ❑ 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." r The nt m t all for required inspec Complete drawing on reverse side. - .. Signed (W A Title: Date: ' FOR DEPARTMENT USE ONLY ('� Application Accepted by Date 6- Area �/ Date `Z 7 Pit or Grout Inspection Date Final Inspection Additional Comments: s EI Stk 466-6781 ❑ Lodi 369-3621 LlManteca 7104 ❑ Tracy 63 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �) �Q�J + EH 13-24 4REV.1 8 5) (/ � - 6 — .�EH 14-29 -.