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APPLICATION FOR PERMIT i� a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.', STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) f� �1,� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describedRhis a plibam n ;N 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. Job Address r/ Cit Lot Size PM Owner's Name 1 � '%4odress / Phone Ir ontractor tom` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST UCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ED] OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type asing Specifications tet\ M Public 11 Other {1 to Depth of Gr Seal Type of Grout] I I Irrigation _.-Approx. Depth Eastern Surface Seal Insta of by Repair Work Done ❑ Type of Pump H.P. tate Work Done _ Well Destruction ❑ Well Diameter – Sealing Material )top 501 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 —C&fnmercial_ 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 -- --Pr`operty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line SEEPAGE PITS I 1 Depth Size ` Number SUMPS L� Distance to nearest: Well 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, 1 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;afa,California.::.« The applicant m st call for all required inspections. Complete drawing on reverse-side. �J Signed X � { /�� ` � Title. Date: '`" FOR DEPARTMENT USE ONLY Application Accepted by Date r 2 Area Pit or Grout Inspecti by Date Final Inspection by `�" Date i Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-1621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 -e-e Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO — I <,e p� (�"� �// C [� QQ 1 I} +.EH 13-24 tpEV.t i H 5] ��.CJV S . y e- Y —s �`� 7 �JU _AY N EH 14-29