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�,. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1,2091 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. Job Address City e Lott Size sc-Cry PM 1 .[f� � �d _ Owner's Name �-�'� Address�� Phone '" �7 I 368' ria s f Contractus I�^�' �� C Address 6W07 �``� License No.3 y z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.0. _T - -_ _SYSTEM REP �❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.` PROP. LINE FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS .EEE, ti .❑ Industrial ❑ Open Bottom ❑ Ma a Dia. of Well Excavation. ! Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ` I'l Public F] Other n Delta Depth of Grout Seal Type of Grout--. I I Irrigation -Ap Depth f I Eastern Surface Seal Installed by - Repair Work Done D T of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') — Oepth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is = available within 200 feet.) i Installation will serve: Residence_k Commercial_. Other E Number of living units: /J_• Number of bedrooms Character of soil to a depth of 3 feet: S 17 N Water table depth o ` SEPTIC TANK [H"1Type/MCapacity jk_rdt'�? No. Compartments �- PKG. TREATMENT PLT. ❑ f , Method of Disposal ` Distance to nearest: Well I (Z!e,-,) Foundation *b Property-Line 5 / LEACHING LINE IRI No. & Length of lines _ �' Total length/size I FILTER BED ❑' Distance to_nearest. Well I CC � Foundation ��'- Property Line S ry SEEPAGE PITS l I- Depth Size - Number — SUMPS D, Distance to nearest: Well „(Foundation Property Line DISPOSAL PONDS ❑ F 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 Di%trict. 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 applicant must call for all required inspections. Complete drawing-on-reverse side. r Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �_. Date _ Area F � � Pit or Grout Inspection by Final Inspection by / � Data Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 PERMI7'NO. INFO CASH ..EH13-24(REV.iiiis) 76,0wo i EH 14-28 F