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APPLICATION FOR PERMIT �v SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Local Health District. Job Address / / City Lot Size PM Owner's Name Address ! �_ + w r� Phone '-' ` Contractor Address (cense No. ®5—/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ElIndustrial LJOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications M Public [7 Other Ci Delta Depth of Grout Seal Type of Grout 11 Irrigation -__-Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done- --- Well Destruction ❑ Well Diameter Sealing Material (top501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No-mptic-system permitted it public sewer is available within 200 feet.I Installation will serve: Residence -- Commercial— Other .f Number of living units: Number of bedrooms �1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j LEACI-f1NG LINE ❑ No. & Length of lines Total length!/size FILTER-BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i. I hereby certify that I have prepared this application and that the work will be done in accordance wi-th 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, l 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 fallowing: "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. .,�� L'i Signed X Title: ��- _,-- Date: 03 FOR DEPARTMENT USE ONLY Application Accepted by Data Area fit or Grout Inspection by Date Final Inspection by Data 41f Additional Comments: _. i J C4 "` k ❑ 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 REMITTEDCK RECEIVED BY DATE PERMIT'NO. INFO t.EH 13-24IREV-i/85) 7 �-/ - EH 14-26 ✓