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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. i-IAZELT ON AVE., STOCKTON, CA Telephone (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 Address /r City - Lot Size PM Owner's Name �L �` Address - Phone Contractor 147W ' - ' ?_ Address 39d & Cl �£/ 27 License No.scw"�O_ 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private 0 Gravel Pack ❑ Tracy y ing Specifications i f l Public ❑ Other ❑ Delta Depth of Grout Sea Type of Grout I I Irrigation Approx. Depth 1.) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well.Diameter Sealing Material (top 50') _- Depths Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION {DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK '❑ Type/MfgCapacity-- - - No. Compartments a 5 PKG. TREATMENT PLT. ❑ ` Method of Disposal 4 Distance to eaFest: = Well Foundation Property Line ^I LEACHING LINE No. &kLength of lines 7d !r Total length/siz FILTER BED Distance to nearest: Well 6-0 :t: Foundation Property',Line SEEPAGE PITS 11 Depth 5iie ]Number SUMPS ❑ Distance to nearest: Well t Foundation Property Line ' -..- DISPOSAL PONDS ❑ r I hereby certify that I have preparedthis 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 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 certif 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." f t- The applicant must cats re aired ins ctions. plete drawing on reverse de�+ Signed X Title: Date: �� / FOR DEPARTMENT USE ONLY Application Accepted by -• "" Date 'rkArea Pit or Grout Inspection by _ Dat Final Inspection by 1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi .369-3621 El 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED , BY BATE PERMIT'NO. + EH 13-24IREV.1/ss> �]G,oa �1'� Alt i M1� Ict EH 14-28 i}