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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA 3 Telephone (209) 466-6781 } PERMIT EXPIRES 9 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/pump and the Rules and Regulations of the San Joaquin Local Health District. r 6AM , Job Address NiCity at Size PM � 4 Owner's Name Address _�! f/�'1 _ Phone Q r Contractor_7W F, r Address [�� Lice,!Nse' � �� Phone f/t� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI f ❑ Industrial ❑ Open ❑ Manteca Dia. of ion Dia. of Well Casing LI Domestic/Private 17 ell Pack ra a of Casing Specifications f l Public n Other elta Depth of Grout Sea Type of Grout----------. I I Irrigation x. Depth l I Eastern Surface Seal Installed by _ Repair Work Don Type of Pump H.P. State Work Done _ IlkWel ruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is available within 200 feet.I i Installation will serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms ., f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Co nts PKG. TREA PLT. ❑ E. , r_.... ethod of Disposal rest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines E length/size f FILTER BED ❑ Distance to nearest: e!I Foundation Pro ine SEEPAGE PITS i I Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL P S ❑ I h y 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 Ca' The applican all it inspeati Comple drawing on rev"e side OVSigned X Title: /` �f �T `Date: 4 r FOR DEPARTMENT USE ONLY , .,W I Application Accepted byDate Area 0 2 el I Pit or Grout Inspection by Date Final Inspection by Additional Comments: 0 9_r ❑ Stk 466-6781 ❑ Lod 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 CASH RECEIVED BY DATE PERMIT'NO. ♦ EH 1 -241REV.I/H51 S 3 S EH 144-28