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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '1 1601 E. HAZEL 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. .lob Address g` City of Size PM Owner's Nbame Address_333 � Phone Contracto Address2_21 a• - License No! Phone �I TYPE OF WELL/P MP: NEW WELL ❑ WELREPLACEMENT ❑ f' PUMP INSTALLATION L~SYSTEM REPAIR Q- OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SE firR LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC TORE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS ❑ industrial El Open Bottom 1-1 Man a Dia. f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of sing Specifications I`I Public Cl Other Cl Delta Depth of Gr t Seal Type of Grout I I irrigation _Appro epth I I Eastern Surface Seal In lied by _ Repair Work Done ❑ Type o ump H.P. State Work Done Well Destruction ❑ W` Diameter Sealing Material {top 501 f i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l 1 DESTRUCTIoNXSJN0 septic system permitted it public sewer is W available within 200 feet.► Installation will serve: Residence_ Commercial— Other Number of living unit`s': Number of bedrooms Character of soil to a'depth of 3 feet: Water table depth „ SEPTIC TANK Cl Type/Mfg. 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 ❑ Distance to nearest: Well . Foundation Property Line �p 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 4 rules and regulations of the San Joaquin Local Health Diatrict. 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 foi•which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican ust call for all required inspections. Complete drawing on reverse side. Signed Titla - 1..y ___ Date: FOR DEPARTMENT USE ONLY Application Accepted by __ Date Area a Pit or GroutInspectionDate Final Inspection by` Date ` a + Additional Comments: (s� Z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 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 CASH /� RECEIVED BY DATE PERMIT'NO. +.EH 1324(REV.I/A 5) '�/ EH 14-26 [JZI 17 (J�