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APPLICATION FOR PERMIT , r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781' 4 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 insta€l 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. I Job Address �. I J � �✓-`�8�✓ ty, Lot Size PM Owner's Name - lfdress -ct`� - PhoneLJ1,;1 `cam t, _ - .� ��•�. Contractor fi� _ Address License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .' PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATI ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 171 Gravel Pack El Tracy r�4a�T�R Casing Specifications. -. 1'1 Public n Other ❑ Del ate! Depth of.Gro_ut Seal _ Type of Grout I ! Irrigation x' __Approx. D I Eastern surface Seal Installed by Repair Work Done ❑ T imp . H.P. State Work Done Well Destructio Weil Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ti Number of living units: Number of bedrooms . + Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t r Method of Disposal Distance to nearest: `=Well Foundation Property.Line ty` LEACHING LINE ❑ No. & Length of lines Total length/size xVV=?? FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS J l Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ S"r 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 taws of California:"Contractor's hiring or sub-contracting signature l certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections...Complete drawing on reverse side. Signed - Title: g +c Date: FOR DEPARTMENT USE ONLY 1-^ Application Accepted by Cn.,N!nQ— Date, _ AreaV ell, 1( 1] Pit or Grout Inspection by Date Final Inspection by 1 - Date L= Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED (CASH RECEIVED BY HATE PERMIT'NO. ♦.EH13-24IREV. /n5) EH N-2a (/