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F � _ s APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT k4s l 1601 E. HAZE T ON 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 G Local Health District. Job Address / s9< `s� � � Cit Lot Size PM � Owner's Name fit/ ` � � C Address Contractor ' /E Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTAN AREST: SEPTIC TANK SEWER LINES DI FLD. PROP. LINE UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF ROBLEM AREA . C UCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Of Well Excavation Dia. of Weil Casing { ❑ Domestic/Private ❑ Gravel Pack cy �Tye of Casln Specifications [I Public f} Other ❑ Delta th of Grout Seal of Grout 1 I Irrigation ..App Depth . I 1 Eastern Surface Seal installed by - Repair Work Done (01 Ty Pump H.P. State Work Done ( Well Destruction ❑ all Diameter Sealing Material [top 50'] `�} ! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTIO No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial L Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:_ Water table depth s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal + Distance to nearest: Well ' Foundation Property Line I I LEACHING LINE.,, 0 No. & Length of lines Total length/size � FILTER BED ❑ Distance to nearest:` Weil'.- Foundation Property Line �+ SEEPAGE PITS i I Depth Size Number r SUMPS L� Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby certify that t 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 Di?;trict. 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 whiclti this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant must II f all a ired irNpections. C plate drawing on reverse side. 495' ~ f q r Signed Title: _ � i//1f� Date: `c5—� FOR DEPARTMENT USE ONLY Application Accepted by Date J Area Pit�orfGrPut Inspect m y Date Final Inspection by /01-0 4 7V-^/Jr-r'``te-/Date ' 'Lllsl'�G1�"S�O�'-�'J'IrS•�Gr..r e-�• Nofi'S.c K. lJ��fl q"C�EOs�l�j-/� O'�..�I✓EQ •r Ad_drltiolnal Comments: r w '' ❑ Stk.4fi6-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 � 3 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 3fyq�q.a- � w�essc-rte l� 5�Cre� !! FEE _ MOOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMI7'NO. INFO I +.EH 13-24(REV.I/H s) > EH 14.28 '