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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 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 A'flide in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin `Local Health District. Job Address [ L`hi�r--- City Lot Size a'✓ PM Owner's Name e2 Address _�� Contractor J Gd , Address License Now Phone TYPE OF WELL/PUMP: NE ELL ❑ WELL R PLACEMENT ❑ 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by tIN. y Repair Work Done ❑ *ype_rof,Pump H:P. State Work Done l-""I i Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material iBelow 50') , �1 TYPE OF SEPTIC WORK:I NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: � Number of bedrooms Character of soil to a de nth of 3 feet Water table depth t tir SEPTIC TANK Type/Mfg Capacity No. Compartments v" PKG. TREATMENT PLT. ❑; Method of Disposal Distance to nearest: Well Foundation Property Line " ' 1 J LEACHING LINE A No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ^'%❑. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑; hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and e 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 subjectect to workman's compensa- tion laws of California." The applicant must all required in onjs. Complete drawing on rover side. �^} i w.i[` (/ Signed X Title: Date: FOR DEPARTMENT USE ONLY � ___, Application Accepted by Date Area Pit or Grout Inspectio DateFinal Inspa tion by Date Additional Comments: kasR ' C3!" z ii _ ❑ Stk 466-6781 ED Lodi 369-3621 El Manteca 823-7104 C1 Tracy 835-6 385 ] r� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED h�„ CASH�, `. RECEIVED BY-. DATE PERMIT`NO. � + EH 13-241REV.1/861 - EH 14-M 1 ,