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€ APPLICATION FOR PERMIT 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. r ,lob Address � ( �j�s�l4 City Lot Size PM Owner's Named Address phone { SI Contractorf:ZI Address PLicense No. �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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i Fl Public n Other ❑ Delta Depth of Grout Seal Type of Grout. _ I 1 Irrigation _.-App(ox. Depth I l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') { Depth Filler Material {Below 50 _ TYPE OF SEPTIC WORK: NEW INSTALLATION !'I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is f _ ,.-,-` _E--ti-avadable within 00 feet.) ) -Y j� -Installation will serve:_-Residence commercial-_ Cher her— Number Number of living units: _ Number of bedrooms �. Character of soil to a depth of 3 feet 4bp 2 45' Water table depth SEPTIC TANK ❑. Type/Mfg Capacity CXR No"iCompartmenis 1 PKG. TREATMENT PLT. Q j Method of Disposal r Distance to nearest: Well .'tel_-'-Foundation"_.'Property Line_30 LEACHING LINE ❑ No.& Length of lines\_ 9 T9tal length/sire E FILTER BED i❑ Distance-to nearest, ~ Well I Foundation ; Property Line { SEEPAGE PITS fl ,Depth -,Size_M1 SUMPS CI Distance to nearest:.."-,nearest:.."-, Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I f sive preparad,thjs application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ! rules and regulations df 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 followingt"I certify that in the perforrrtiance 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 fpr all r quired inspections•�,Cpmplete drawing on reverse side.} F _ Signed X E7itle: �«�� — Date: j FOR DEPARTNIEIYT-USB ONLY'-..: / I Application Accep�ed by Date Area Pit or Grout Inspection by DatJ Final Inspection by Date-� ! i r Additional Comments: i ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Retulrn all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. box 2009, Stk., CA 95201 ( i FEE _+ r.g.K _ _ _ f INFO AMOUNT DUE AMOUNT MITTEEI _CASH' RrC�TVED I3Y`'�7� 1 DATE~ PERMIT IVO. + EH 13-2/IREV.i i H 5l EH 14-28