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: ,. a f APPLICATION FOR PERMIT * S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 a 46 /� City f Lot Size PM �. ��s.r Owner's Name Address Phone z �� Contractor -Address a Address QS 13 �_ S • � eyik f icense N � d Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME=NT © DESTRUCTION ❑ PUMP INSTALLATION M. —. . .SYSTEM-REPAIR.❑ ._, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS ROP. LINE FOUNDATION AGRICULTURE WELL THER WELL 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom A nteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing £ Specifications n Public n Ll Delta Depth of Grout Seal ° Type of Grout I I Irrig�WorkLLI --Approx. Depth l I-Eastern surface Saul Installed by _ Repair Type of Pump H.P. State Work Done Well D Weil Diameter Sealing Material (top 50') n Depth Filler Material Welow 501 `J} TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIO No septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character-of soil to a depth of 3 feet: Water table depth SEPTIC TANK /''' ❑ Type/Mfg V Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll 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 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." The applicantinust call for all required inspections. Complete'diawing on reverse side. Signed X Title: Date: FOR DQEPARTMENT USE ONLY Application Accepted by Date (0—m—u Area Pit or Grout Inspection b ata Final Inspection by Dat��q r Additional Comments: �- -1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca k 63-7104 ❑ Tracy 835-6365 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 j ASH JRECEIVED BY DATE � PERMIT IVO. + EH 13-241REV.1/H51 d _ '�j '"r� EH 14-26 4{�