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APPLICATION FOR PERMIT T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephohe (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. 9 ,^/ Job Address �� C �' �� rQ ��`P_ � City �)4&/ "Lot Size Q t P,-e- Owner's Name ' Yl�. 1T f Address 71 7 NJ Phone �Q Contractor Address ' License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP ANK SEWER LINES DISPOSAL FLD. PROP. LINE FDUNDATIO AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL EM AREA CO CTEON SPECIFICATIONS ❑ Industria! ❑ Open Bottom © Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac f Casing Specifications I'1 Public F] Other elta Depth of Lit Seal Type of Grout _ I I Irrigation __-Approx. De I I Eastern Surface Seal stalled by _ Repair Work Done ❑ Type of P H.P. State Work Done _ Well Destruction ❑ W lameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DE=STRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 5' Installation will serve: Residence Commercial___,_. Other Number of living units: _�_ Number of bedrooms '77?1 f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg C1�GYP. Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' � / Method of Dispopl Distance to nearest: Well Foundation 14) Property Line sr r LEACHING LINE LET—No. & Length of lines ev C', Total length/size 7s- FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7 SEEPAGE PITS I I Depth �- Size J _ T Number � W 6CAe•t-t" SUMPS Ll Distance to nearest: Well `(J DU -� Foundation � Property Line 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 Di1trict. 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." 1. The applicarje4st call for all re red s ions. arppl/ drawing on reverse side. Signed X Title: [ bate: (� F'R DEPARTMENT USE ONLY Application Accepted by Date Area ! �f Pit or Grout Inspection by ADate Date Fiinal Inspection by { Additional Comments: � - ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 843-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE OUNT REEmiTTED CK RECEIVED BY DATE PERMIT N0. +.EH 13-24 1REV.t i n 51 .� f �y-!} EH 14-26 (�/