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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781,M : .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y - (Complete in Triplicate) r 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. t _ Job Address Cityve!!��ot Size PM Owner's Name ' y �C.� h Address �^ Phone (.r �� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW INES DISPOSAL FLO. PROP. LINE FOUNDATION AG E WELL OTH ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTI ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy___ _ a_of_ ' _ S _ � ,_ pecifications ❑ Public ❑ Other ❑ Delta Depth of Grout eal Type of Grout ❑ Irrigation ---Approx. Depth ❑ ern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamete Sealing Material (top 501 N Depth Filler Material (Below 501 N I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-ODESTRUCTIONN (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__ Commercial_ Other Number of living units: Number:of bedrooms Character of soil to a depth of 3 t: Water table depth SEPTIC TANK El Type/Mfg Capacityr No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F dation Property Line LEACHING LINE CJ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation Property Line SEEPAGE PITS E Depth Size Number SUMPS El Dist �tonearest: 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. _ certifies the following:nature agent's Home owner or licensed a signature g g:`"I certify that in the performance ofthe_work for which this permit is issued, !shall not employ any person in such manner as to become subject to workman's compensation laws of Califom'ia' 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 EMELicant.musj4all for all requi fi.. i9spections. Complete drawing on reverse side. Sig ed Title: Date: ! OR DEPARTMENT USE ONLY Application Accepted by Date x`67 Area 103 Pit or Grout Inspection b Date Final Inspection by _ Date Additional Comments:° weti 6 -rs ❑ Stk 466-6781 O Lodi- 369-3621 ❑ Manteca W-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 + EH13.24(REV.iia 5) EH 142838