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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT i J 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1€ (Complete in Triplicate) M 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 D'%,,,- City-32 i ' t. Job Address City� 6\ Lot Size PM Owner'' Name Address d b .� !/ T Phone �' —A/ski ' n I Contractor Address License No. Phone J TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT CI DESTRUCTION ❑ I i PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER ❑ �5 + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE W L OT WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR TIO PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of W avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type CasingSpecifications —f 11 Public FI Other ❑ Delta th of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done LJType of Pump H State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 �i. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is k 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 E' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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."Contractors 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." T cant st c f r all requir inspections. Complete drawing on reverse side. Signed Title: Date: .a FOR DEPARTMENT USE ONLY —6p / Application Accepted by Date Area (, � Pit or Grout Inspection by Date Final Inspection by 1 _ Date—. Additional Comments: a'Ht ❑ Stk" 465-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY DATE PERMIT NO. 1 INFO CASH ♦ EH13-24(REV.1/0 57 � ,S �-,�j t�_ �7._,t,.� EH t4-ZB a