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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED4'� (Complete in Triplicate) Tdecompliance y made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is wit�h San Joaquin County rdinanr�e No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. C'l�'� TIM Job Address S, s 4 City_C" -c T'a_ Lot Size lela z PM -�. 14 Owner's Name n Address �a / O Phone / t Contractor 'P`w Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREARUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack cy Type of Casing Specifications — M Public Ll Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _. x. Depth I I Eastern Surface Seal Installed by Repair Work Da0e ype of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION availableNo �within e200 feet.) if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth (\ SEPTIC TANK Type/Mfg l Capacity No. Compartments (� PKG. TREATMENT PLT. 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 SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 applicast call fora requir Aspecti S. Complete drawing on reverse side. In Signed X / Title: ��/�/ ! Date: �� FOR DEPARTMENT USE ONLY Application Accepted by Date � ^ Area Pit or Grout Inspection bif\ Date Final Inspeetioon by Date Additional Comments: r , �r U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 ✓ `� •7� 1��6 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J (l FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 1 -�-73.241REV.i S51INFO s�7 3S.vJ !o� EH 14-26 �N