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APPLICATION FOR PERMIT SAN JOAQLhN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 ' City Lot Size PM j]\Owner's Name t l Address ✓1 , ��i Com!-* P Phoney 01 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA/RR T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLD. PROP. LINE II FOUNDATION AGRICULTU LL 1_,OTHER WELL PITS/SUMPS I' INTENDED USE TYPE OF'WECL `""PROBLEM AREA t N'S 'UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of We Excavation - Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin SpecificationsC.D C1 Public C7 Other Cl Delta Depth of Grout Se Type of Grout I I Irrigation _Approx. Depth I Eas n Surface Seal Installed r Repair Work Done ❑ Type of Pump H.P. Stat Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTAI TION I] REPAIR/ADDITION I I DESTRUC 4ONX(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Residen C mercial Other Number of living units: er bedrooms Character of soil to a depth of 3 feet: Water table-depth. SEPTIC TANK ❑ TypelMfg Capacity ': ,No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 'E LEACHING LINE ❑ No. & Length of lin s Total length/size r FILTER BED ❑ Distance to nearest: Foundation Property Line SEEPAGE ITS I'] Depth Size Number SUMPS L-I Dist a to Barest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pr76arOlhis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of theSan,,Joaquin Local Health Di§trict. Home owner or licensed a nt's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall not i 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,1 shall employ persons subject to workman's compensa- tion laws of California." p�nThe applicant. ust call for I.r quired inspections. Complete drawing on reverse side. ��Signed X4 r' Title: _ ?Y14J�� Date: J f '� USE ONLY ) Application Accepted by ok� • �' Area Pit or Grout Inspection by Date Final Inspection by Date 2 J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 OU�NT DUE AMOUNT CASH CASH CK RECEIVED BY DATE Q �PERMIT-NO. I +.EH 1 '24 1REV.i I 51 EH 144-28 i