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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Cou ty Ordinance No-549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addressi-7 L , / 1 City 576 sF2 ,Lot Size A 2 _PM d � � ]� !K -int Phone Owner's Name ^> Address 1 10 Address License No, Phone Contractor � "��"` � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac ype of Casing Specifications I, Fl Public ❑ Other e ❑ D to Dep Grout Seal Type of Grout I 1 Irrigation �.Approx. Depth l I Eastern Surface Seal ns by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Finer Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is vailable within 200 feet.I Installation will serve: Residence Commercial_ Other n Number of living units: . Number of bedrooms Character of soil to a depth of 3 feeC Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance*to nearest: Well Foundation Property Line LEACHING LINE ❑ No. lir Length of lines Total length/size �h FILTER BED ❑' Distance to nearest: Well Foundation Property Line t j r +i SEEPAGE PITS. 'l 1 Depth Size _ Number SUMPS _ ❑- 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. I 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 pb!son in such manner as to become subject to workman's compensation laws of California." Contractors 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 ust call for all required inspections. Complete drawing on reverse side. s Signed X �� — Title: gg Date: FOR DEPARTMENT USE ONLY Application Accepted by Date rea Pit or Grout Inspection b Date Fi al Inspection by Date v Additional Comments: +' I a'�` �r `C ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant . Return all.copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 _ s 1 FEE INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.ItN5) EH 14-26 -