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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephorle (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 Addres 2F` C- Lot Size PIVI Owner's Name Address Phone � � Contractor Addres 1... License No. Phone TYPE OF W /PUM NEW WELL ❑ MLLhEPLACEAENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FO ON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca of Well Excav - ia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Specifications n Public .Cl Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type umpi H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I.1- REPAIR/ADDITION I I DESTRUCTIO I o septic system permitted if public sewer is i 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:"I Water table depth SEPTIC TANK r;y. ❑ Type/Mfg: Capacity No. Compartments PKG. TREATMENT PLT. ❑ -I . Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LJ Distance tonearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number F SUMPS L1 Distance to nearest: Well Foundation Property Line 7 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 District. Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not—P 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 applic st all for all re ired ' s ctions. Complete drawing on r verse side. [ r \ Signed X. Title: Date; rt• FOR DEPARTM NT USE ONLY Application Accepted by ^`- Date _. s. Pit or Grout Inspection b Date Final Inspection b Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l.� , FEE AMOUNT DUE AMOUNT REMITTED INFO C RECEIVED BY (� DATE PERMIT'NO. +,EH 13-24 lREV.tik51 6H 14-28