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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 r` 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. C� /} ,:$I" - Job Address 4n�C 7C'' 1`J City Lot Size PM Owner's Nama�l I � ��J�'71(_�� / Address + T T� Phone 'r C; Contractor r Autq 1 C. Address ! L L cense NoaC ` Phon -- TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O(� D CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y ON AGRICULTURE WELL OTHER WELL PITS/S INTENDED USE TYPE OF WELL PR CONSTRUCTION SPECIFICATIO ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Exc Dia. of Well Casing El Domestic/Private 0 Gravel Pack ❑ Tracy o Casing Specifications ❑ Public ❑ Other C]] Datta Depth of Grout Seal Type of Grout ❑ Irrigation } �4pprox_-0e�O Eastern Surface Seal Installed by Repair Work Done ❑ of Pump H.P. State Work Done Well Des�r' ❑ Well Diameter Sealing Material (top 501 Depth Filler,Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is voila Iwith in 200 feet.) Installation will serve: Residence_____ Commercial� Other Number of living units:' Number of bedrooms ;t �. Character of soil to,a depth of 3 feet: 1 Water table depth . SEPTIC TANK I '" ❑ Type/Mfg Capacity l No. Compartments PKG. TREATMENT PLT. ❑ _ w Method of Disposal Distance to nearest: Well Foundation A Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ll . Distance to nearest: Well Foundation ' ` Pro ^n y `party Line SEEPAGE PITS " ` ❑ Depth Size f Number a SUMPS ❑ Distance to nearest: Well 'Foundation Property Line DISPOSAL PONDS ❑ t 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. 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 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 applica mtjst II'for alirequired inspection . Complete rawing on reverse side. J Signed Date: / s 1 FOR DEPARTMENT USE ONLY Application Accepted by Date f —` Area S i x ? t -7 j Pit or Grout Inspection by Date Final Inspection by ! Data c Additional Comments: are yZ-y_i k � "❑ Stk 466-6781 ❑ Lodi 369-3621 t ❑ M nteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Pe it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT.REMITTED CK CASH BY DATE PERMIT'NO. + EH 14-26IREV.1i85) 4 CJ CV/