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. l APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT (� 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 12091 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 2scribed. 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. 1 / Q Job Address City �� Lot Size.. Y+ 1 a PM —6wner's Name U I� 1 �7 ��A- Address a Phone _Contractor �I Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTA CE TO NEAREST-. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOlJNDATiON AGRICULTURE WELL th PITS/SUMPS a INTENDED USE T ELL P EA CONSTRUCTION SPECIFICATIONS i El Industrial ❑ Open teca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ravel Pack ❑ Tracy of Casing Specifications f'1 Public ❑ Other ❑ Delta Depth of Grou Type of Grout _ 1;1 Irrigation AApprox. Depth I I Eastern Surface Seal In by Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ WellPameter Sealing Material (top 501 A Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKl ❑ Type/Mfg Capacity No. Compartments \, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 0 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,I SEEPAGE PITS i I Depth Size Number ,I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin counly 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 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 C 'ornia-" f i _ i The appiica mut call for all required in c'ons. Complete drawing on averse side. 1 Signed X ` Title: 0 to Date: Pe �I FOR DEPARTMENT USE ONLY ! / Application Accepted by Date �—` Ara r 3 � rte Pit or Grout Inspecti �I Date Final Inspection by Date J, Additional Comments: ❑ Stk 466-6781 ❑ Lodll 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 .a INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24{REV,v/N 51 `� r EH 14-26 Coe J