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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7'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 t' I City Lot Size X PM Owner's Name �/4 Address 1 Phone _ Contractor /�T`��A,r�CL�� Address 00 TYPE 0 T WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 DISTANCE TO NEAREST:'SEPTIC TANKOTHER SEWER LINES �__�4 plSPpSA I FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE TYPE OF WELL PROBLEM AREA C ER WELL PITS/SUMPS Jr I ❑ Industrial CTION SPECIFICATIONS �+- ❑ Open Bottom ❑ Man~ to — Dia. of Well Excavation F1 Domestic/Private ❑ Gravel Pack Dia. of Well Casing ( 11 Public racy Type of Casing Cl Other n DeltaDe Irrigation pth of Grout Seal Specifications - f I I rte^ IApprox. Depth I I Eastern Type of Grout Surface Seal Installed by Repair Work Doype of Pump p H.P. Well De ction ❑ State Work Done _ Well Diameter Sealing Material stop 50'I Depth Filler Material Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ('I RE PAIR/ADDITION I.) DESTRUCTIO 1 INo septic s Other ystem permitted if public sewer is Installation will serve: Residence_ Commercial available within 200.feet.1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth ! PKG. TREATMENT PLT. ❑ Capacity _ No. Compartments Distance to nearest: Well Method of Disposal Foundation Propdrty.Line__� LEACHING LINE r l ❑ No. $ Length of lines FILTER BED ❑ Distance,to nearest: Wsll Total length/size Foundation Property Line�� SEEPAGE PITS I f Depth' SUMPS p Size Number Ll Distance to-nearest: Well DISPOSAL PONDS ❑ ' - Foundation Property Line_-�� rules and regulations of the San Joaquin Local Health District. 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 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 1 certifies the following: "I certify that in the Performance of the work for which this permit is issued,!shall employ tion laws of California." p Y persons subject to workman's compensa- tion ant must for all squired ��7` rawing on reverse side. Signed X Title: �7 Date: FOR DEPARTMENT USE ONLY Application Accepted by vVJt bate �+ Area Pit or Grout Inspection b ? Date Final Inspection by Additional Comments: y ' Date ❑ Stk 466-6781 ❑ Lodi 369-3621 - �� ❑ Manteca 104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 t —0ki-e T`t, FEE AMOUNT DUE U /� h ;i INFq AMOUNT REMITTED c RECEIVED BY p� DATE PERMIT Nt]. V ) r,E1i1314IREV,F/H5l �j�_.0EH 14-26 �/ �5� Z Zr— k