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APPLICATION FOR PERMIT SAN JOAQUI!N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 I City-I Lot Size PIVI Owner's Name Address 4 0 Phone G Contractor JrZA dxl. Address Las- diALio. Jcense N �f' 7 Phone i G TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SSTEM REPAIR 17 OTHER ❑ DISTANCE TO"NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " ' FOUNDATION' AGRICULTURETE OTHER WELL PITS/SUMPS "J" INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y e of Casing Specifications 1-1 Public ❑ Other (711 Deltat' , r pth of Grout Seat Type of Grout I 1 Irrigation --Approx. Depth I 1 Eastern uriace Seal installed by o ` Repair Work pone ❑ Type of Pump H. State Work Done-_ Well Destruction ❑ Well Diameter Sealing Material [top 501 `y Depth Filler Material igelo TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION ['vr DESTRUCTION'i 1 (No septic system permitted if public sewer is " t available within 200 feet.) ` Installation will serve: Residence— Commercial V"Other Number of living units: Number of b roamsr I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK y ❑ Type/Mfg1. Capacity No. Compartments PKG. TREATMENT PLT:❑ : 1 ' '"Lir Method of Disposal � 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &'Length of lines Total length/size r FILTER BEC] ❑ Distance to nearest: Well 1v v'` foundation�� Propertine SEEPAGE PITS l I Depth Size (Number SUMPS ❑ Distance ton rest: Well _ Foundation Property Line At- DISPOSAL PONDS ❑ = 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. x 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, 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 applican ust call fo require inspections. Complete drawing on reverse side. Signed Title: __ Date: R DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by�- �:y� � / Date 'r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-21 iREV.i/n5Y K R!