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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED (Complete in Triplicate)— 'l 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. 41 Job Address < ah City + Lot Size PM f r Owner's Name f 55 Address Phone Contractor �. Address r 4 144–?—License No.3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER LINES _�_��-DISPOSAL FLO. PROP. LINE FOUNDATION A /CULTURE Wj L•L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A E CONSTRUCTION SPECIFICATIONS I� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ .racy Type of Casing j Specifications i r-] Public Cl Other Delta Depth of Grout Seal ` I Type of Grout I I Irrigation '. .-Approx. Oe f 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') Depth Filler Material /Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITIOW,,IJ DESTRUCTIO fNo septic system permitted if public sewer is J" available within 200 ieet.l 1` Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 E Water table depth SEPTIC TANK LlType/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . , Distance to nearest: Wells#. Foundation Property Line w ..� i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED X ❑ Distance to nearest: Well rFoundation Property Line SEEPAGE PITS I'I Depth Size - { Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i 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, at 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 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." ' I .The applicant call for all inspections. Complete drawing on reverse side. j Signed X Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by AkI Date Pit or Grout Inspection by Pate Final Inspection by ate "! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE S INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. CASH + EH 13-24(REV.1/8 5)