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APPLICATION FOR PERMIT ,. SAN JOAQUIN LOCAL HEALTH DISTRICT ti 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Cl-n,1r, y4✓ : (Complete in Triplicate) Application is hopeby made to the San Joaquin Local Health District for a permit to construct and/or install the wor rein described. Thi applic is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and e n Joaquin Local Health District. J Job Address ` City Lot Size PM VIA • . � r � PhoOwner's Nam9 �ress o� Contractor ' , Address01 Gsf I ` ! Ph 6,-Cy". License No. 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 FOUNDATION AGRICULTURE WELL . OTHER_WEL01T5/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRU.CT40N S ECIFICATIONS ❑ Industrial ❑ Open Bottofn"""-'❑1 1Mb teca -df-W611-Excavation—--- —-Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications z` ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---A f.Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ pe of Pump H,P. State_Work (lone Well Destructi ❑ Well Diametes I '`" Sealing Material (top 501 + Depth i ' f Filler Material (Below 501 TYPE OF SEPTIC WORK: rNEW INSTALLATION I 1 REPAIRlADDITION I I "" DESTRUCTI lNo septic system permitted if public sewer is available within 200.feet.I14 Installation will serve: Residence Commercial_ .0th 1 Number of living units: Number of bedrooms l r Character of soil to a depth of 3 feet: r` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �-W-� -foundation"� Propeirty.Line CA LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to�nearest: Well I Foundation Property Line ' j SEEPAGE PITS 11 Depth I Size Number SUMPS ❑ Distance to.nearest: Well + Foundaiion!t. t f Property Line DISPOSAL PONDS ❑ t 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 cornp6nia—tion Iaws o{California." Contractors 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 lifomia." 5 " The applica ust call for all requir inspections."Complete drawing on rev se side. E Signed Title: Date:" !f FOR lS0ARTMEAIT USE ONLY Application Acceptedbyt Date Area r Pit or Grout inspectio date Final lnspectian by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 952.01 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK a RECEIVED BY DATE PERMIT-IVO. r.EH1 -24(REV.1/xsl ` 3S, C ) / EH 144-28 ••3