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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 District. Job Address 'forCity Lot Size PM Owner's Name H"�5 �✓ Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � " . DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL] ) y• ' IOTHER SWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA1IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public� ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --- App!ox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump' H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing terial_Itop 501 Depth Filler Material (Beloww—W TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 fNo septic system permitted if public sewer is availa-ble-,within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Numhor 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 r / Distance to nearest: Well_ "_G_euadation Property Line V .� 1 LEACHING LINE ❑ No. & Length of lines w I Tptal length/size FILTER BED 06 Distance to nearest: Well _._ Foundation 1 Property Line S SEEPAGE PITS l I Depth I Size i . Number SUMPS r Cl Distance to nearest: Well `Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application alnd that the work will be d ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DRtrict. --,-Horne owner or licensed agent's signature certifies thJ following: "I certify that ii i the performance of the work for which this permit is issued, I shall not f .employ any person in such manner as to become subj4ct-to-wer4mraWs-43empensation laws of California."Contractor's hiring or sub-contracting signature w 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 Califo The applicant ust cal for`all re ired inspections. Complete drawing on reverse side. / igne X t Title: Date: 0 r �i r= FOR D A ENT USE ONLY T f T _ 7 Application Accepted by r ! Date /c Area -5 Pit or Grbut Inspection by :--- Date Final Inspection by Date Additional Comments: ! f 1 ❑ Stk 466-6781 ❑ Lodi 36-973'621 �❑ Manteca ;'623-71 ❑ Tracy 635-6385 �kl Applicant - Return all copies to: Environmental Health Permit/Servicesi 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMUUN I AtmiTTto— CASH RECEIVED BY �y DATE p� PERMIT'NO. +.EH 17-2h4REV-4-49.5Y------• EH 11-28 7`b r -' --4��_-_.. ._ r/ r-J ,.,• {! 'T J � � �t• ••