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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 '� 4 PERMIT EXPIRES 9 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,ems \7�y7�l� Job Address Q t,'� 4� City Lot Size PM f I Owner's Name --� . / _ )iic, Q Address ."'� Phone Contractor Address License No. Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP FOUNDATIO ICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST RLTCTtOECI ONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ asing `Spee+fi tions F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth tern Surface Seal Installed by Repair Work Done ❑ Type of Pum H.P. State Work Done_ Well Destruction ❑ Well eter Sealing Material ;top 50'1 h Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is rr � available within 200 feet.] (A Installation will serve: Residence— Commercial_ Other G Number of living units: Number of bedrooms 0 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number T SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Tn 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 •f1� rules and regulations of the San Joaquin Local Health Di§trict. " 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 applican must call for II required inspec/tiro s. Complete drawing on [averse side. Signed �� ! Title: f�C> r� Date: v FOR DEPARTMENT USE ONLY Application Accepted by Date Area 4 Pit or Grout Inspection by Date Final Inspection by Date ! 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. �` t-E 4 H 1 -241REV.riws) � t 3-s ��/ EH 14-26