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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. f 1 ///Ij e Job Address _� r , /� � ;�7 City V ` 1 Lot Size PM S+ r r Owner's Name Address r Phone /DDS c��,.,� A- . 3 y�v 57) Contractor __Address License IVo. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE FOUNDATION AGRICULTURE WELL O ELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS 4 ❑ Industrial ❑ Open Bottom ❑ Manteca . of Well Excavation Dia. of Well Casing F-1 Domestic/Private ❑ Gravel Pack ❑-Tra'cy Type of Casing. Specifications F] Public 171 Other elta Depth of Grout Seal Type of Grout_—_. I I Irrigation —..Aper pth l I Eastern Surface Seal Installed by - Repair Work Done C7 Ty a of Pump H.P. State Work Done Well Destruction 11 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION.[.I REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted if public sewer is k available within 200 feet.) Installation dvill serve: Residence_ Commercial— Other ti :E Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/site FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 of California." The applicant t call for all required i spectio s. Complete drawing on reverse side. Signed Title: Data: O FOR DEPARTMENT USE ONLY �+ Application Accepted by Date "Cl 91, Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 ❑ M nteca 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, w\ INFO �} +.EH13-241REV.Iik51 EH 1426