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k APPLICATION FOR PERMIT 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 Districts Al City Lot Size IlA �N �. s:. ,/..7 PM Job Address (� Address AR -- Phone Owner's Name _6 1 A�C3 � Contractor 6e [1 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO�r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ "OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE FOUNDA GRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTTIONS R (_1 industrial LI Open Bottom ❑ Mante Dia- of Well Excavation -Wlell Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications ' ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ED Irrigation �, rox�epth ❑ Eastern :, Surface Seal Installed by > p. Repair V Done ❑ Type of ump H.P. State Work Done Well Destruction ❑ Well Diameter 'Sea'ling Material-ltop 50')-' Depth Filler Material (Below 50'1 j TYPE OF SEPTIC WORK: NEW INSTALLATION EIava REPAIR/ADDITION ❑ DESTRUCTION 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 k PKG. TREATMENT PLT. ❑ Method of Disposal 4 _ Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 Sari'Joaquin Local Health'District..' - -7 N4 I a . 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." Coritractor'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 steal)employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ,r � I Signed Title: Date: /f- r _ FOR DEPARTMENT USE ONLY kApplication Accepted by Date / Area Pitor Grout Inspection by Date Final Inspection by Date- Additional Comments: t ❑ 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 AMOUNT DUE, AMOUNT REMITTED CK# RECEIVED 8Y: DATE �i7 �`P`EJftM1/T NO. INFO /©� s• V /�/�/ r ij 7J / O / �`J� '`+ EH 13-24 IREV.)/n 51 T�( EH 14-28' .--