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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. Job Address r/ 5,-)3-�eH re`City Lot Size I PM Owner's Name Address s!�JQ r Al Contractor _r^ `H u" ��.,_ ! Address S Licens No. _0,3_ hone TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE ❑ Industrial ❑ Domestic/ Private * Public I I Irrigation Repair Work Done ❑ Well Destruction IK V NEW WELL ❑ WELL REPLACEMENT ❑ 44DESTI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL_ TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack ❑ Other Approx. Depth Type of Pump Well Diameter Depth D , OTHER ❑ PROP. -,LINE - PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Tracy Type of Casing Specifications ❑ Delta Depth of Grout Seal Type of Grout _ I I Eastern Surface Seal Installed by H.P. State Work Done '( Sealing Material [top 501 —11 4111 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 1' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Water table depth 'E Capacity No. Compartments l . Distance to nearest: Well Foundation Method of Disposal . Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line n SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, 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 The applicant us II I required inspections. Complete drawing on�reverse J/side. /GfY—!' Signed X Title: DY -4 =1-e Date: A FO EPARTMENT USE ONLY J i Application Accepted byDate ��iz Area w Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: -- ►- -,Ai ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 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 i, r EH 13-24IREV. I/n5 EH 14-2e FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �IPERMIT'NO. rDATE � u.