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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 ° F. PERMIT EXPIRES TYEAR FROM DATt'ISSUED 4 (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`. i ( �� 'k Job Address � ' • City Lot Size PM Owner's Name fT = �? C ddGssPhone Rt o %w�i 62. D C � � _"Phone's :Z6f6 Contractor Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _,OTHE9_EI .....�..0 DISTANC T: SEPTIC TANK., SEWER LINES f- f]ISPOSAL,F.LD. PROP. LINE FO AGRICULTURE WELL `"`OTHER'WELL'-I PITS/SUMPS` INTENDED USE TYPE OF WELL' P AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom El Manteca of Well Excavation � Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of as x Specifications Fl Public a; O>Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation .,, 4 _:-Approx. Depth I 1 Eastern . Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_____ Commercial_ Other Number of living units: f Number of bedrooms Character of soil to a depth of 3 feet: C Water table depth x SEPTIC TANK ❑ Type/Mfg I Capacity _ No. Compartments ' PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: t Well 'Foundation Property Line { L F 4 LEACHING LINE kr-."No. & Length of lines _�" ��`T - Total length/size U T I -FILTER BED ❑ Distance to nearest: r Well Foundation l0oT Property Line (III 4 r= 1 SEEPAGE PITS PT Depth Tr 76Q_-'722t _ LNum ber SUMPS L-i Distance to nearest: Well y� Foundation(`/� Property Line l4h�F7` DISPOSAL PONDS ❑I r 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.DFstrict- .�.. -•._- - .- .�. ,.� _ 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 certif hat in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's cot'npensa- tion laws of California." I The applicant must call r re a pe s. Complete drawing on reverse side. Signed X � Title: Date:"001V e lr z p,7 FOR DEPARTMENT USE ONLY i Application Accepted by CMQ Date 2�5II Area V y" Pit or Grout inspection by Date b,5 (Final Inspection by Date Additional Comments: ` 1 ❑ Stk 466-6781 ❑ Lodi •369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ," I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. a EH 13-24(REV.I H5) EH 14-28