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az APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 } '.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 } (Complete in Triplicate) Application is hereby made to the San Jo quin Local Health District for a permit to construct and/or install the work herein described.TMs 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. 7 Job Address 8/. i C �� City Lot Size PM Fto Owner's Name ll7A } �� Address 32TIhone +� Contractor's Name License No. SID M5 t Phone r TYPE OF WELL/PUMP: EW WELL tli WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 71SYSTEM REPAIR LlOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l {� -Industrial ❑ Open Bottom VVanteca Dia. of Well Excavation_ / Dia. of Well Casing E7 V6omestic/Private Gravel Pack ❑ Tracy Type of Casing VC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout t ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction C1 Well Diameter Sealing Material Itop 501 Depth I Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is , available within 200 feet.) Installation will serve: Residence I Commercial_ Other 4 Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet:I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal mm Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size III FILTER BED ❑ Distance to nearest. Well Foundation Property Line k� ti I 1- SEEPAGE PITS 1, ❑ Depth I Size Number SUMPS i C] 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in accoridance 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 ust call for all req/Lied inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPA MENT USE ONLY Application Accepted by ) Date Area r Pit or Grout Inspection b Date 34--&r Final Inspection by Date r ��J Additional Comments: k-1–,!f4 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO }� I + EH 13-24(REV.10/e3) EH 14-26