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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name ddress S Phone LQ Contractors Address License No. Phone 3ak 3 a ; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ I' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI CIFICATIONS fD Industrial ❑ Open Bottom_ ❑ Manteca Di ell Excavation Dia. of Well Casing L ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other eta Depth of Grout Seal Type of Grout 1 I Ifrigation "�._Ap epth l l Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H.P. State Work Done_ Well Destructi ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Belo 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ZxOmmercial— Other Number of living units: Number of bedrooms __,-_ + _ Character of soil to a depth of 3 feet: {I f Water table depth SEPTIC TANK t ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to;nearest: Well, Foundation Property Line I I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 F SEEPAGE PITS i I /bepth Size ymber SUMPS I Distance to'nearest: Well !_ Foundation ti: Q`! 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 I rules and regulations of the San Joaquin Local Health Datrict. Home owner or licensed agent's signature certifies the following: "1 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 a 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 must call for II r Ir d ins pie ons. Complete drawing on reverse side. r Signed X._._y ; _ Title: X90 Date: 1 { DEPARTMENT USE ONLY �y Application Accepted by Date - Area / d i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I 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 Y RECEIVED 6 INFO H DATE. PERMIT'NO. ♦.EH 13-24 IREV.I i H 51 /'i r��(/ ate'l'J L• EH t4-ZB [