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r APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 C;=_ �l •�� h��//J' / City �~ • Lot Size PM Owner's Name [ Ess Contractor � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION LJ PUMP INSTALLATION C1SYSTEM R ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTU ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PeLEMCONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing❑ Domestic/Private Cl Gravel Pack Type of Casing Specifications i`l Public n Other Cepth of Grout-Seal Type of Grout I I Irrigation Approx, Depth IS ace Seal Installed by.Repair Work Done ❑ Type of Pump State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION 1 1 DESTRUCTION INo 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 f 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 became 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 call for all required inspections. Complete drawing on reverse side. }p � Y\' ('Signed X Title: Date: z V `� ; '9 '] Ile I\ G FOR DEPARTMENT USE ONLY ApplicaAAccepted by Date G ^� - Area Pit or Grout Inspection by Date Final Inspection by Date —z Additional Comments: © 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 FEE INFO AMOUNT DUE AMOUNT REMITTED GSIt H RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/n5) �J EH 1A-28