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,n APPLICATION FOR PERMIT e y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAS 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" a� City Lot Size 73 40.. PM x Owner's Name /r��""' A Address ' Phone 7 Contractor Address ` - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑. WELL.REPL CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL WELL OTHER WELL—PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o_ ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca g Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout eal Type of Grout I I Irrigation —.Approx. Depth l I Easter Surface Seal Instal by - Repair Work Done ❑ Type of Pump H.P. ` —; tate Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO (No 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 I Character of soil to a depth of 3"feet: Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal [ Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number P SUMPS U Distance to nearest: Well 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 Q rules and regulations of the San Joaquin Local Health District. 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, I shall not r 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." r The applicant mus all for all req red inspections. Comp to drawing on reverse side. y`Signed X Title: _ /!Lv v"' --- Date: 41 rP r ff �� TMENT USE ONLY r Application Accepted by Date 11-41 U Area [L( Pit or Grout Inspection b Data lwiel Inspectio y �D.�Y Pb2lutr __�_ "% Date !� c Additional Comments: �d �� 0,X, �� t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 . ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 t FEE OUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH13.24tREV.1/n5) JrOb (3� EH 14-26 r