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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781, PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ 1AZ�/ --"City Lot Size PM Owner's Name 'J Address [� 1 7 _ Phone 2 Contractor Address y�ense No. a Phone_9- d TYPE OF W U NEW WELL EI WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ig, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPT1CfTANK s SEWER LINES -DISPOSAL-FLO. PROP. LINE —. FOUNDATION .AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation --Approx. Depth t 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump ILK im. H.P. 3 Z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i.I REPAIRIADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve:' Residence_ 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ „ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ! r - SUMPS Cl Distance to nearest: Well Foundation � Property Line r 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 applicant must ca "or all"required inspections. Complete drawing on reverse side. CS Signed X Title: Date: f j FOR QEPARTMENT USE ONLY {I Application Accepted by2aDate 1 � Area ]74 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: a ❑ 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 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIYNO. + EH 13-24(REV.1/H5) EH 14-28