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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 I made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 tor well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � Zc City tLM1 Lot Size PM Owner's Nam �`- "� Address Phone i Contracto Address 7 G License No. Z2 Phone TYPE OF WELL/PUMP: - NE11V WELL ❑ - WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE - FOUNDATION AGR( TURF WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROB AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t-1 Public ❑ Other 71 Delta Depth of Grout�Seal Type of Grout I Irrigation pprox. Depth I I Eastern Surface Seal ln3talled by - Repair Work Done ❑ ype of Pump H.P. State Work Done_ Well Destruction Well Diameter Sealing Material [top 50'1 Depth Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I RE'PAIRIADDITION l i DESTRUCTION I t INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: —/— Number of edrooms 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 �j Total length/size J r FILTER BED ❑ Distance to nearest: Well _ Foundation �� / Property line - SEEPAGE PITS I I Depth 11 r Size' i i1` Number SUMPS 01 Distance to neatest: Well,. Foundation t6 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, l shall employ persons subject to workman's compensa- tion laws of California." Theapplicant must II for all required inspections. Complete drawing on reverse side. g Signed X -Q Title: Date: 75_3/ 0 FOR DEPART ENT USE ONLY Ap lication Accepted by Date , i Araa l or rou Intion by Date �� Final Inspection by Date. r Additional Comments- 0 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24(REV.1 I AS) EH 14-26