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APPLICATION FOR PERMIT 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/of 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. /{ 74 Job Address _TO 57 ,kyr P . City _ Lot Size PM Address Name CKj Address WC Phone contractor _ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I] PUMP INSTALLATION ❑ SYSTEM REPAIR 171OTHER El DISTANCE TO ST: SEPTIC TANK SEWER LINES DISPOSAL FI D PROP. LINE ION AGRICULTURE WELL ft WELL PITS/SUMPS INTENDED USE TYPE OF WELL NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca 11 Excavation Dia. of Well Casing O Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifications I'1 Public - Other ❑ Delta Depth of Grout Seal a of Grout i I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by _ Repair Wor Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter -/Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I 5ESTRUCTION o septic system permitted if public sewer is ' t available within 200 feet.] Installation will Server 'Residence Commercial— Other _ Number of living units:+ Number of bedrooms ' Character of soil to a depth of.3 feet: °' Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method df Disposal f Distance to nearest: Well + ,Foundation ;Property Line " x LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS, I I Depth SizeNumber i SUMPS El Distance to nearest: Well Foundation. Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will-pe done in accordance.with 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, I shall not employ any person in such manner as to b6come subje 16 workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performa 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 a r r ctio . Complete drawing on reverse side, j Signed X Titie: Date: / FOR DEPARTMENT USE ONLY (� Application Accepted by Date �J � "eS Area ' Pit or Grout Inspection by fDate Final Inspection by Date I Additional Comments: /Lne& ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CSR RECEIVED BY DATE PERMIT'No. + EH 1 -24]REV.i i n 5) � EH 144-26 LJ �'