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APPLICATION FOR PERMIT �u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781V two PERMIT" EXPIRES 1 YEAR FROM DATE ISSUED r � � ► ,;, (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 r fes,. _ City OC Lot Size PM Owner's Name �1Fol C� 7 Address }5 MiG ek d Phone 5- yg 15 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL - OT LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications El Public ❑ Other � .] Delta Depth of Grout Seal Type of Grout ❑ Irrigation X. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done Well Destru ' ❑ Well Diameter Sealing Material atop 50'1 ' Depth Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is y available within 200 feet.l Installation will serve: Residence_ Commercial ,Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -- - Water table depth SEPTIC TANK Type/Mfg r Capacity. No. Compartments ' PKG. TREATMENT PLT. k Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 5 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 licant must call for all required inspections. Complete drawing on reverse side. Signed Title: �� _.._ Date: 1 1�4 7 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 4 Pit or Grout Inspec n by Date Final Inspection b Date 4 _...d Additional Comments: ❑ Stk 468-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy erAirm 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 CK CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.i/a 51 V ,O - ! fly C - G'�,. Ll j 'EH 14-28 �.!' '" U