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APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT { 1601 E. HAZEL T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 'f 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 '-- G r I e— Cit Y Lot Size �f�� ply '] Owner's Name. a `��I' Address Phone 1�69-90 70 Contractor U [!� � ddress License No. ? hone ..� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEARES L] 11 SEP ANK SEVER LINES k DISPOSAL FLD. PROP._UNE— FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P M AREA CONSTRUCTION SPE-0F7CATIONS �-- ; ❑ industrial ❑ Open Bottom ❑ Mantecat Dia. of We xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy C] Public f pe ° Specifications Other (� Def Depth of Grout 5e Type of Grout _ I I Irrigation Type Dept Eastern I Surface Seal Installed by ,) Repair Work Done ❑ Type of H:P. State Work Don Well Destruction ❑ DiameterSealing Material (top 50'I Ii Depth Filler Material 18elow 501 P TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence— Commercial_ 'Other r Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: f """"P' " """1 - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments PKG.,TREATMEN7 PLT. ❑ ,; r I Method of Disposal � Distance,fit nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED r ❑ Distance to nearest: Well Foundation Property Line ,L SEEPAGE PITS 11 i Depth Size Number SUMPS ❑ Distance to nearest: well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. 11 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 peyon 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 ealifornia." f The applicant must call fora quired in actions. Complete drawing on reverse side. Signed Title: Date: _ # FOR DEPARTMENT USE ONLY Application Accepted by / D Date 6 Area n Pit or Grout Inspection by Date1P - Final Inspection by Date Additional Comments.- ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca a23-7W ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE y INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. , CASH + EH 13 -24 EH 1 4-2e