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PAYMENT 3 RECEIVED APPLICATION FOR PERMIT � � SAN JOAQUIN LOCAL HEALTH DISTRICT MAY 0 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES VYEAR FROM DATE ISSUED PERMITJSERVICES (Complete in Triplicate) Application is he+eby 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. Jab Address ity Lot Size PM ' ;Zcue�4 Owner's Name Address 01 `` Contractor Address JS License No. Phone J� S3 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 WELL PITS/SUMPS, F; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indu ial ❑ Open Bottom ❑ Man a Dia. of Well Excavation Dia. of Well Casing omesticlPrivate ❑ Gravel Pack racy Type of Casing Specifications f"1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout { 1 Irrigation _Approx. Dept l YEastern �u ace Sea nstalled by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material Itop 50'1 Depth r Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION 111No septic system permitted if public sewer is I available within 200 feet.I N I �y Installation will serve: Residence �'+ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments s PKG. TREATMENT PLT. ❑ Method of Disposal t� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-ato nearest: IWell Foundation Property Line SEEPAGE PITS i I Depth —Size Number f. SUMPS Ll Distance to nearest: Well Foundation Property Line ;ZDISPOSAL 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. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work fol 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 California." f The applicant must call for all required inspections. Complete drawing on reverse side. � r^ Signed X Title:, Date: a F R DETMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Date S Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,Applicant- Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / E AMOUNT REMITTED 'RECEIVED BY DATE PERMIT NO. FEE AMOUNT DU r INFO r EH 13-244FIE V.iiH51 a EK 14-26