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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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/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 Dist rict. /� Job Address -Y' � _ �^ �� City Lot Size PM Owner's Name �R � y L Address K y 5t A/ + _ Phone t, 66 7-gd0 Contractor r Address License No. Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ D TRUCTION ❑ P STALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CON STRUCT(ON SPECIFICATIONS ❑ Industrial ❑ Open Sotto anteca Dia. of Well Excavation Dia. of Well Casing '�� O Domestic/Private a Pack ❑ Tracy a of Casing Specifications ` 71 P f} Other ❑ Delta Depth rout Seal Type of Grout I I Irrigation _.-Approx. Depth 11 Eastern Surface Seal In by Repair Work Dane ❑ Type of Pump H.P. State ork Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION)\(No 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 TANK ❑ 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ID 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 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: 1 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 applicant must call for ail required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT SE ONLY Application Accepted byxa� Date Area Pit or Grout Inspection by Date Final Inspection b /ti1� Dafe Additional Comments: O4> El Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ racy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 160 E. Hazelton ve., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED [CASH RECEIVED BY DATE PERMIT NO. r EH 13-24{REV. b EH 14-2e jT �/