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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I,('� �jJ f J j y� j� y Job Address I f jy t'`" v" #9�, N� � '" /!' City Lot Size PM Owner's Name D rt7 Address I f W to A�5 L K.1 Phone Z16 r r 9'7 Contractor _..__""�r/;q"'^ 'Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P E 1 NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE ELL PROBLEM AREA CONSTRUCTION ATIONS �hl� ❑ Industrial LJ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing ❑ Domestic/Private .❑ Gravel Pack ❑ Type of Casing Specifications F1 Public ❑ Other - elta Depth of Grout Seal Type of Grout { I Irrigation ox. Depth 12 Eastern Su Seal Installed by Repair Work Done Type of Pump H.P.. State Work Done _ Well Destructi n ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is Mo within 200 feet.i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Characterof soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L] _ t. _ ,! f 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 I I Depth Size Number SUMPS L_� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .171 -- 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 law f C Arnia." The appli call for all required inspections. Complete drawing on reverse side. �f Signed X Title: IT(/L� I _______ Date: /0 FOR DEPARTMENT USE ONLY Application Accepted by Date �( Area Pit or Grout Inspection by Date Final Inspection by Date- Additional Comments: t ❑ Silk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies t : Environmental Heal h Permit/Services 1601 E. Yzelton Ave. O. Bax 2009, Stk., C 55201 FEE AMOUNT DUE AMOUNT REMITTED I C K H RECEIVED BY DATE PERMIT'NO. INFO EHt3-24(REV.26 t/H 51 �s �� f / „r >� EH 14- L