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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i' 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 t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -�� l�Y Job Address 7"% Sa City N� C ki�_4-1_ot Size PM I Owner's Name S�Y�� 4 {'i//7 1 k' Address OfI4 e Phone 1 (? t Contractot v Address License No. Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION 17 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER I-INES 'DISPOSA PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C} Gravel Pack racy Type of Casing I Specifications ❑ Public n Other 1 Cl Delta Depth of Grout Seal Type of Grout n n f VJ I I Irrigation pprox. Depth I 1 Eastern r Surface Seal Installed by _ xJ Repair Work Done Type of Pump H.P: State Work Done Well Des on 0 Well Diameter Sealing Material`{top 50'1 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I-1�-REPAIR)ADD IFION-+-I—BESTRUCTIOKI-JW Wo 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; i Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size 14 FILTER BED ❑ Distance Fto nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number _. 1 SUMPS Ll Distance to nearest_: Weil Foundation Property Line DISPOSAL PONDS ❑ 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: "I certify that in the performarice of the work for which this permit is issued;I shall employ persons subject to workman's compensa- tion laws of California." I i The applican must call foIt required inspections. Complete omplete drawing on reverse side. Signed X� AO&.,L Title: Date: f FOR DEPARTMENT USE ONLY Application Accepted by "I 1 Cr1t� Date "�y lam� Area Pit or Grout Inspection by Date Final Inspection by Date Adoitional Comments: r� G off 7 ) /C? lI v i q/Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Alicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 35201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CAS r EH 1321(REV.i i H 51 EH 11-26 �,