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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. IL GJ w� Job Address Ora— Cityak_"_QJLot Size ply 4e ef Owner's Name Address phone Contract 1. 0 L1 Address License No. P_6J_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR} OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP..LINE. _ I FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ZE2nomstrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I �'l Public D Other L] Delta Depth of Grout Seal Type of Grout _ I I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ED of Pump _..._ H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {tog 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is 6 ` 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 I � ) PKG. TREATMENT PLT. ❑ -� v`f 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 V SEEPAGE PITS I 1 Depth Size Number -SUMPS Lel• Distance to-nearest:--Welt - Foundation ---property DISPOSAL PONDS ❑ 1 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 Di$trict. 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 per n n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the Poll g: "!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 Ca"ornia." The applic t call for all r fired inspe t' ns. Complete drawingon v rs side, j i Signed X Title: Date: i,�r FOR DEPART SVT USE ONLY Application Accepted by Date "' Area' , J Pit or Grout Inspection by Date Final Inspection by Date � 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 i i FEE AMOUNT DUE AMOUNT REMITTED CK R INFO CASH RECEIVED 9Y DATE PERMIT"NO. EH 144 ♦.EH1 -241AEV.iinSl 1/ WQ -28 }