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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 —2 Cit Lot Size PM (� t Owner's Name J Address Phone Coritracttir �"Adaress' License No. Phone x TYPE OF WELL/PUMP: NEW ELL C] WELL REPLACEMENT ❑ DESTRUCTION L 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER L DISTANCE TO NEAREST: SEPTIC TANK SEW LINES `-* DISPOSAL FLD. PROP, LINE FOUNDATION A (CULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PRO L AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open sBditom•'"I 4 ❑'M teca Dia. of Wel.Ezcavation Dia. of Well Casing # L Domestic/Private L Gravel Pack t ❑ r cy Type of Casing Specifications I I`1 Public F1 Other ' +. D to Depth of Grout Seal Type of Grout _ I I Irrigation _.'AWrox'Depth% 7East rn Surface Seal Installed by Repair Work Dune—❑i Type of Pump H.P. State Work Done_ Well Destruction ❑ •Well Diameter Sealing Material (top 50') f 1 s b f Depth a Filler Material (Below 50') 1�} t TYPE OF SEPTIC WORK: NEW INSTALLATiON I REPAIR/ADDITION i.I DESTRUCTION l I (No septic system permitted if public sewer is I 1 a available within 200 feet.) 1 Installation will serve: Residence�" Commercial Other --� Number of living units: Number of bedrooms -3 0 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ,P Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal + -1 [ l Distance to nearest:• Well t!—foundation ZD IL Property.Line_ 7�` r !I 0 LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED ❑ Distance to nearest: arlNell/�� oundation �_-� Property Line SEEPAGE PITS Depths Size ` Number 2 SUMPS ❑ Distance to nearest: Well _ Foundation w. property Line j i 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 t 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, I shall not f 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 compense- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: } FODEPA MENT USE ONLY } Application Accepted by _ L Area Aa Date _ p # iter Grout Inspection byate / —�y-��al Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6355 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 VK I I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. f INFO CASH I ..Yr.EH..1 -21[REY.t/n51 EH 4 {