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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES TYEAR 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 d the Rules and Regulations of the San Joaquin - I Local Health District. C( 12 Q Jab Address O ity of Size L PM Owner's Name Address SCTr"' `�`- 7 Phone+L _ F Contractor �~! s - V�= icense Nol 7" Fhorie `�� S TYPE OF WELL/PUMP: -'NEW'WELL-L WELL REPLACEMENT ❑ DESTRUCTION Cl _4 PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ DISTANCE70 NEAREST; SEPTIC TANK SEW LINES DISPOSAL FLO. PROP: LINE " I FDUNDATlON G CULTURE WELL ', OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEAEastorn REA CONSTRUCTION SPECIFICATIONS ❑ Industrial "�. ❑ Open BottomDia- of Well Excavation bia. of Well Casing ❑ Domestic/Priv e ❑ Gravel PackType of Casin Specifications---,�! t ❑ Public ' ❑ OtherDepth of Grout Seal ; Type of Grout I I I Irrigation F� ` g-Approx. DSurface Seal Installed byRepair Work.Done�El Type of Pump State Work'DoneWell Destruction ❑ Well Diametering Material Itop 50'1 €Depth lle Material IBelow 50') {�(� TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/A DITION I I DESTRUCTION I I (No septic system permitted if public sewer is v11 available within 200 feet.) p� Installation will serve: Residence Commercial'— Other Number of living units: Number of bedroom Water table depth Character_of,soil.to a depth of 3 feet: _ � P SEPTIC TANK - -'A ❑ ;Type/Mfg. a ty, tNo. Compartments PKWTREATMENT PLT=❑ `' $Method of Disposal 2 .4 Distance to nearest:. Wel ;Foundation- - - ';-"Property.Line - t LEACHING LINE ❑ No. & Length of tines A7 Tota! length/size FILTER BED ❑ Distance to nearest: eln ! Property Line r - SEEPAGE PITS l I Depth Size '� ?y Number F SUMPS " r ❑ Distance to nearest: Well /0 d "''Foundation�_ Property Line 11 DISPOSAL PONDS ❑ . 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 Di?;trict. Home owner or licensed agerit'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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature 4 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 a'ppficantAiust call fo require inspections. Complete drawing on reverse side. Signed X Title: 44.4 1`4 j Date: U �� ' R 15 P,ARTMENT USE ONLY - l� Application Accepted by _ Date Area Pit or Grout Inspection by Data Final Inspection by ' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEEZ NT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. INFO t +.EH13-24iREV.tiK51 �T EH 14-2e ! V t