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4� APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 z PERMIT EXPIRES TYEAR 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/ g qg_ Job Address City of Size �J� "/ l PhoneCQ Owner's Name i �f,/. Contractor� Addres License N_ 7 'RPhone. TYPE OF WELL/PUMP: NW WELL Et— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST41LATiON 1� SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA K _f__a ` ,&_43EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI I� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y oc ❑ Industrial ❑ Open Bott p ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P4-O f stic/Private ravel P ck ❑ Tracy Type of,Casing Specifications j a� (l Public F1 Other 1=1 Delta Depth of Grout Seal Type ut I Irrigation _-Appro Dept I I Eastern Surface Seal Installed by - I Repair Work Done ❑ Type of Pu p5EM._ti H.P. State Work Done Well Destruction ❑ Well Diame r Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: /,,NEW IN ALLATION I1 REPAIR/ADDITIONyI I DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dis a to nearest: Well Foundation Property Line r 1 LEACHING flfvE Cl. No. Length of lines Total length/size FILTER BED ❑ Distce to nearest: Well Foundation Property Line SEEPAGE PITS C I De Size Number SUMPS 11 - Dis a to nearest: Well T foundation Property Line I DISPOSAL PONDS O I hereby certify that I have'prepare '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 J uin Local Health District. Home owner or licensed agent's sig lure 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 to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: '1 certify that the performance..f the work for which this permit is issued,I shall employ persons subject to workman's-compensa tion laws of California." " The applicant mu call for all r d inspectio mplete drawing on reverse side. ' ~' Signed'X X +� �_ Title: r" Date: FOR DEPARTMENT USE ONLY NQ JI Application Accepted by Date `� rV Pit or Grout Inspection by (oma' / oat e T Final Inspection by r Date 1 r / { Additional Comments: I ❑ 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 0 CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.1/145) �b5 EH 14-26 (((