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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT EXPIRES TYEAR FROM DATE ISSUED (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 I Local Health District. Job Address .Z 1f/ �� l� �4G.d ' Cit l mac-4 Lot Size PM r V � _` , F Owner's Name �✓��"- - /1_19Z -7-/// -Address +�" Phone Contractor ��! T Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT��SPOSALFLD.__l ION ❑ E PUMP,INSTALLATION ❑ SYSTEM REPAIRER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBIL REA STRUCTION SPECIFICATIONS w ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Weil Casing ❑ Domestic/.Private ❑ Gravel Pack ❑ Tr pe of Casing Specifications FI Public ❑ Other Delta"'�'*'�`Dep -of-Grout-Seal----^---' Type of.Grout i I Irrigation Approxi. De l I Eastern Surface I Installed by _ Repair Work Done ❑ Type of Pur H.P. State Work Done_ ' Well Destruction ❑ Well Diameter Sealing Material Itop 501- Depth Filler Material {Below 501 t a ? TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION X (No septic'system permitted if public sewer is available within 200 feet.i s Installation will serve: Residence_ Commercial. J. -Other. Number 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 Uv Distance to nearest: Well Foundation 'Property Line R � V 5- LEACHING LEACHING LINE ❑ No. & Length of lines Total length/size Q 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 taws of-California."Contractor's hiring or sub-contracting signature certifies the following: "I rtify that in the performance of.the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Califor - The applicant m t c for all required i pecti s. Complete drawing on reverse side. -� ....-,_ R- -_ :1 Signed —z-. L Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate L p Area k Pit or Grout Inspection by Date Final Inspection bDate d i Additional Comments: G� u P ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant Ret n all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r Gj,/1 EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO +.EH 13-24(R£V.14K5) • EH 14-28 1