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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 1209) 466-6781 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 Na. 18P for well/pump d the les and ReguJag6nvof the San Joaquin Local Health Districts lL� �^ If _00741 Jab Address P City M�L[�iFG4 Lot Size PM Owner's Name Address Phone Contractor �~ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications LJ�l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ,r ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler"Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 171DESTRUCTION F1 (No septic system permitted if public sewer is rl .-r available within 200 feet.) Installation will serve: Residence� Commercial Other Number of living units:_/_ Number of bedrooms !!q� » Character of soil to a depth of 3 feet: 9aJ®1/ .4459-AVL, Water table depth SEPTIC TANK ❑ Type/Mfg j Capacityo� No. Compartments PKG. TREATMENT PLT. ❑ r `� �' Method of Disposal Distance to nearest: Well Foundation Property Line ZC!!& y— LEACHING LINE No. & Length of lines �' Q `' Total length/size F� FILTER BED ❑ Distance to nearest: Well ZIfV _ '_Foundation Property Line SEEPAGE PITS ❑ 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 N 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all wired inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY 0 Application Accepted by iI '� Date gArea >/ , Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO, + EH 13-24 MEV._1 8 5) EH W26 •Q � ��