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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone Q09) 466-6781 PERMIT EXPIRES TYEAR 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. s,�t C Job Address � / City k/ Lot Size PM Owner's Name ^-oey1. � G Address ��1/ / Phone �"f "U Contractor_ [=�.� Address '96-6 41�✓L^ License No.Jam_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. INF FOUNDATION AGRICULTURE WELL OTH PITS/SUMPS _ V� INTENDED USE TYPE OF WELL PROBLEM AREA CONS N SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications 171 Public ❑ Other F Delta Depth of Grout Seal Type of Grout _ I I Irrigation pprox. Depth I I Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done_ I Well ction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION,\(No septic system permitted if public sewer is h available within 200 feet.) 1 ' Installation will serve: Residence_ Commercial_ Other 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 n 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 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, l 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 parsons subject to workman's compensa- tion laws of California." E plicant m t call for all required inspection . omplete drawing on reverse side. Signed Title: __ _ Date: f 5��7 FOR DEPARTMENT USE ONLY 1� Application Accepted by Date �� Area Pit or Grout Inspectio Date Final Inspection by a Date ar $7 Additional Comments: ❑ Sik 466-6781 ❑ Loch 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY HATE PERMIT NO. r EH 13-21(REV.1 IM 51 EH 14-26