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APPLICATIO.N,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone 12091 466-6781 �� APERMIT EXPIRES 1 YEAR FROM DATE ISSUED _.(Complete,in Triplicate) T Application is hereby made to the San Jdaquin 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.-G' : Job Address ozLV Ci LotkSizt{..:57�k_ PM Owner's Nam ` i Address 9 l ,., Phone 9 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WE REPLACEMENT ❑ DESTRUCTION ❑ ' r PUMP INSTALLATION ❑ S EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCA SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of I Excav ion Dia. of Well Casing ❑ Domestic/Private ❑ Grave) Pack ❑ Tracy Type Casing Specifications ❑ Public ❑ Other ❑ Oelta D th of Grout Seal Type of Grout �- ❑ Irrigation ----Approx. Depth- ❑ Eastern . Surface Seal Installed by Repair Work Done ❑ Type of Pump I - r„ H.P. Statek Done Well Destruction ❑ Well Diameter- Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence t Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ { Method'of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 11 ❑ Distance to nearest: Well ` Foundation Property Line SEEPAGE PITS ❑ Depth } Size ' Number j SUMPS ❑ Distance to nearest:, Well Foundation- Property Line a DISPOSAL PONDS ❑ I 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 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." r ` The applicant mus II for all requir cti ns. Complete drawing on reverse side. X Signed X Title: Date: 4 fOR DEPARTMENT USE ONLY r �` Application Accepted by ! Date `le Z Z- T Area C) / Pit or Grout Inspection + Date Final Inspection by j Date Additional Comments: .f ❑ Stk 466-6781 ❑ Lodi 369-3621 t. ❑.Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental He lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE t AMOUNT REMITTED- ASH RECEIVED BY DATE PERMIT NO. 1&D k . + EH 13-24[REV.,/»sf / �� EH 1428 r