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i - I i -� APPLICATION FOR PERMIT �, F��7S ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 3 € PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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. 4 Job Address l I / c 4� CityR Lot Size L PM -t^ Owner's Name 47,0 R<ILJA Address U/ If, Phone Contractor Address License No. Phone TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISP LD. PROP. LINE FOUNDATION AGRICULT E WELL THER WELL PITS/SUMPS INTENDED USE -TYPE-OF WELL -PROBLEM AREA -C RUCTION SPECIFICATIONS I 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of C\Inst Specifications 0 Public ❑ Other Delta Depth of al Type of Grout ❑ Irrigation �Ap x- epth ❑ Eastern Surface Sfled by - Repair Work Done ❑ Type of Pump H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler.Material (Below 509 . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) } Installation will serve: Residence_ Commercial_ Other Numtier of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a I Distance to nearest: \W.I -- Foun Property Line r'! } LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to neares#: e11 Foundation Property Line { t kf t S SEEPAGE PITS ❑ Dept Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 3 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 sliall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sidnature 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- MInspectio lifor ia." ut all for all r uire s ctians. Complete drawing on reverse side. ' r. Title: Date: nC FOR EPARTMENT USE ONLY "y cepted Date Q6�`� Area +! spectio y Date Final Inspection b Dat �Z.3 Additional Comments: ❑ Stk 466-6761 ❑ 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 + s FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.+/95) { EH 1125