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APPLICATION FOR PERMIT ' 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. �6 Job Address City Lot Size PM Owner's Nam Address Phone # Contractor &X4�/_Ad'dres ( —Ak icense IV Phone —,S , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ 9 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WECL`—"""""OTH PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing LT Domestic/Private - ❑ Gravel Pack ' Type of Casing Specifications ` 1-1 Public Cl Other C] Delta Depth of Grout Seal Type of Grout _ I i Irrigation rox.-Depth I I Eastern 'Surface Seal Installed by e Repair Work Done ype of Pump H.P. "�T State Work Done _ Well Destruc' ❑ Well Diameter '� Sealing Material Stop 501 C Depth Filler (Material (Below 501 q� TYPE OF SEPTIC WORK: NEW INSTALLATION I1- REPAIR/AODITION (J DEST R U CTION.4AlQ Wo septic system permitted if public sewer is yr, vailable within 200 feet.) Installation will serve: Residence. Comm&cialOther Number of living units: Number of bedrooms --- -x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. r _ Capacity 'No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal i 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 j Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. I 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, 1 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 ust call for all required inspections. Complete drawing on re rse si e. Signed - ��-�� g � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by t y e t 1 Date Area Pit r Pit or Grout Inspection by f Date Final Inspection by Date Additional Commen L ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 I n 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 CK CASH RECEIVED BY �yDA E PERMIT NO. ap EH 14-28EN 13-24 1REV.liN 51 3:�� " '+ d`k O P ��/Z. s