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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 ! }y /1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y.,, , .��.•.r1 - (Complete,in Triplicate) Application.is hereby made to the San Joaquin Local Health District for a permit to canstrucand/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 ell/pump and the Rules and Regulations of the San Joaquin Local Health District. " ZL r Job Address City Lot Size / PM Owner's Name Address �� _ Phone 3 $X,5,4 0 Contractor's Name License No. S 72 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK--t i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --I—Approx. Depth ❑ Eastern Surface Seal Installed by Repair.Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 $ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ve DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence C/ Commercial_ Other r: � . Number of living units: Number of bedrooms ' i' �7 F Character of soil to a depth of 3 feet: ��^'fA�)1:. .> Water table depth /o SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT:❑ "' d Method of Disposal ; Distance to nearest: Wel ' r' Found ion` - Property Line EjiNt I L> . 0 LEACHING LINE o. & Length of lines � Totallength/size' �'� r FILTER BED ❑ Distance to nearest: Well f Foundation 2d 1 `Property Line f - SEEPAGE PITS LAY Depth.?g Size Number .3 r SUMPS ❑ ,Distance to nearest: Well .I ' U .""" Foundation a3 Property Line') f r' DISPOSAL PONDS Ll Jand I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin county ordinances,state la rules and regulations of the San Joaquin Local Health District. 1 r 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 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." t t, The applicant must call Jor all loquired inspections. Complete d1ing on reverse side. ' { Signed Title: eew AJ,4, Date: . y FOR DEPARTMENT USE ONLY a f' Application Accepted by Date Area` Pit or Grout Inspection by Date Final Inspection by Date - �. "tet - --.� .. i_ . ...:• „�......-_ -.__Y_.-. -� .,.-" -,,.-.-...;,..��.r r � Additional Comments: r .. �— ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca'\82:3-7104 ❑ Tracy 835-6385 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 CASH RECEIVED BY DATE PERMIT'NO. INFO EH W28 + EH 13-24(REV.10183) �♦