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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 r Local Health District. Job Address R ` p City Lot Size PM Owner's Name 1, C Address Phone 6C 1.01 Contract ddress License No. hone TYPE OF W LLI MP: NEW ELL ❑ WELL REPLACEMENT F-1DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ LJ Domestic/Private ❑ Gravel Pack LJ Tracy Type of Casing Specifications FI Public fI Other n Delta Depth of Grout Seal., Type of Grout + I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by p - Repair Work Done ❑ Type of Pump H.P. State Work Done_ F Well Destruction ❑ Well Diameter Sealing Material (top 50'1 4 Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION (r] REPAIR/ADDITION l I OESTROCTION l I (No septic system permitted if public sewer is J L available within 200 feet.) Installation will serve: Residence r Commercial _ Other y Number of living units: Number of bedrooms 1 00 �. `. Character of soil to�a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments o rsosal PKG. TREATMENT PLT. ❑ ��} n� > � Method ,( Distance to riearest: Wello �(� undation Pro erty Line LEACHING LINE t ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Wel l .'�'Foundaiion . Property Line i SEEPAGE PITS ( I Depth Size _ Number SUMPS Ll Distance ro nearest: Well/rn!� undation Property Line — DISPOSAL PONDS ❑ L `� 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 d 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, 1 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 m st I it r ad inspec ons Complete rng on r r s' e. Signed X itle: Date: FOR DEPARTMENT USE ONLY Q ' Application Accepted by Date / Area (lit or Grout Inspection by Dat V- Final Inspection by _ 7 ��Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE IPERMITA'NO.. � , � • EH 13-241REV. 'H 11-28 1i65) /