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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) r 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. r I I Job Address City Lot SizeaAePM I Owner's Name � Address Ph6R� Contractor Addre` 3� �,( License Phone TYPE OF WELL/PUMP: . #NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE h FOUNDATION AGRICULTURE WELL OTHER W r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU PECIFICATIONS__. } E © Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other i to Depth of Grout eal Type of Grout I I Irrigation —Appro a th l 1 Eastern Surf.ace Seal Installed by _ Repair Work Done ❑ Pump . H.P. State Work Done_ t £ Well Destructio Well Diameter. Sealing Material It 501 Depth Filler Material(Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION-1 1 DESTRUCTib o septic system permitted if public sewer is t vailable within 200 feet.) Installation will serve: Residence Commercial_ Other r 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: — Water table depth SEPTIC�TANK ❑ Type/Mfg x "�` --`"Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C I _ 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 [I Depth Size Number SUMPS ❑ Distance to nearest: Well j 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 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-contractingsignature 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 6cmpensa- tion laws of California." The applicant t tail for all required in actions. Complete drawing on re se side, —yam Signe Date: FOR DEPARTMENT USE ONLY Application Accepted f Date Area Pit or Grout Inspection by Date Final Inspection by Date JT lAdditional Comments: h r ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.1/R 51 EH 14-26 a a