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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 District. Job Address 6 City Lot Size X-4- " Owner's Name ass - r Rhofie Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP CEMENT CT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 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. ❑ Mantepa 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 h Depth Filler Material lBelow 501 `J TYPE OF SEPTIC WORK: NEW INSTALLATION T REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial_ Other Number of living units:_L_ Number of b rooms Character of soil xo a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. 1-1l Method of Disposal Distance to nearest: Well Foundation 70 Property Line iqd k LEACHING LINE No. & Length of lines r To;al length/size ' FILTER BED [IDistance to nearest: Well A!2 Foundation !71Q Property Line LP SEEPAGE PITS ❑ Depth Size 3 Nunper SUMPS y ❑ Distance to nearest: Well ~ Foundations Property Line DISPOSAL PONDS ❑ 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." Contractors 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 rctionsrse side. Signed Title: Date- 4L/7 FOR DEPARTMENT USE ONLY Application Accepted by Datea-16 Area -_ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED 13Y DATE PERMIT"NO. INFO +EH 13.24 f V.10131 .) EH 1478