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'�Y gw'yICvX.: T 3 APPLICATION FOR PERMIT ' """ SAN JOAQUIN LOCAL HEALTH DISTRICT o 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 Local Health District. c ,lob Address �� Lot Sizq-1 7 �U► PM Owner's Name��Fl/ CI! Address 44 71 qFr"/q r Phone Contractor ' Address License No. Phone TYPE OF WELL/PUMP:- - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ +OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'" DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER-WELL- PITS/SUMP'S * INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU IFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications 1'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout i I I Irrigation prox. Depth I I Eastern, Surface Seal Installed by -r Repair Work Do Type of Pump H.P. State Work Done Well D ction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION l 1 DESTRUCTIONA, septic system permitted if public sewer is ' I ' available within 200 feet.I Installation will serve: Residence_ Commercial Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ r 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 t - SEEPAGE PITS I. I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." Contractors 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 applicant must cao for all r uired inspections. Complete drawing on reverse side. r , Signed X Title: Own Date: I FOR DEPARTMENT USE ONLY i Application Accepted by .Date .Area �, 1 _E• � Pit or Grout Inspection by late J Final Inspection by L .— Additional Comments: ❑ 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 BY DATE PERMIT NO. - INFO H pp^^�� /H rEH13-24(REV.1/951 f7 V "/' `� ff7— EH 14-26 I