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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 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 Districts, Job Address 7 DA. /�[ kogei-s©M City IS Lot Size 'Q0 PM Owner's Name r C ` LD S� Address Phone Contractorl,A)))L—+)N A Ll, CAJ _SAddres License No. � ,YLIQ�Phone Q &15_4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARS SOEP�TICTANK SEWER LINES DISPOSAL FLD. PROP. LINE ON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-,-PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial E3 Open Bottom ❑ a Excavation- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack y e of Casing Specifications 1-1 Public f 1 Other n Delta Depth o Seal Type of Grout I I Irrigation Appro Depth I I 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 _ J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION l I DESTRUCTION i septic system permitted if public sewer is fl� available within 200 feet) Installation will serve: Residence L_--n-mmercial 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 r. 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 D 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, 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 otiowing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Ca'ornia." The applicant �sr for 1 equir ins tions C le drawing on reverse si e. Signed Title: Date: r FOR DEPARTMENT USE ONLY r` Application Accepted by Date Area Pit or Grout lnspecti n b !I r Date rr Final Inspection by Date �y Additional Comments: r{l5�� SeII �w.�it �,. PO T vv {mac yu,_._.. ❑ Stk 466-6781. ❑ Lodi 369-3621 0 Manteca 823-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 kFEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY //// DATE PERMIT'NO. •.EH 13-24(REV.i/H 51 �1I-�W EH 14-28