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E APPLICATION FOR PERMIT U ._ SAN JOAQUIN LOCAL. HEALTH DISTRICT � f 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 L al Health District. Job Address City Lot Size PM Owner's Name Address t-- Phone AM d�rr Contractor�,�A/ < � �i Address License No. Phone -Q YPE OF WELL/PUMP: NEW WE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL AREA C RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i-1 Public ❑ Other 11 Delt pth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I tern Su Seal Installed by Repair Work Done ❑ .. Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION E I DESTRUCTIO (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: + Water table depth SEPTIC TANK ❑ Type/Mfg k 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 ❑ 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 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 applica must call for all required inspections. Complete drawing on reverse side. Signed X ` Title: ate: I FOR DEPART NT USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection by Date Final Inspection by ! Dat Additional Comments: 7 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �[ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 5201 y FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIV@p BY GATE PERMIT NO. + EH 13-24 MEV.