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e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ND (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. his 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 r Local Health District. Job Address bid ° Z,- City:F� ��Lot Size PM Owner's Name L /<CL- Address C: rZ Phone , f I. Contractof rc �' Address �53 License No. d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA 0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P AGRICULTURE WELL PITS/SUMPS INTENDED LZ WELL PROBLEM AREA CATIONS ❑ Industrialtom ❑ Manteca Dia. of Well Excavation ia. of Well Casing ❑ Domestic/Privateck ❑ y Type of Casing Spec,Ic s 1-1 Public n Delta Depth of Grout Seal Type of Grout I I Irrigation . Depth I I Eastern Surface Seal Installed by Repair Work Dop H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 r J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONNo septic system permitted if public sewer is V" vailable within 200 feet.I Installation will serve: Residence— Commercial— Other �COO,/ Number of living units: Number of bedrooms 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 F Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ -Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line # DISPOSAL PONDS ❑ F r 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 District. Home owner or licensed agents 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." �� The applicant mu ca for Prequired 'nspections. Complete drawing on reverse side. Signed X — Title: Data: Y F D ARTMENT USE ONLY r Application Accepted byp Date � Area Pit or Grout Inspection by Date Final Inspection by I • Date Additional Comments: ` c 2L JS AL-41 L ❑ Stk 466-6781 7 Lo I 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE -INF MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. �.EH 13-24(REV,i/"b) z '[ B r� 5 1 r �J {� }ryc.� (}'[ 'f EH 14-28 �.7V r *--�"1 U V '�._