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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) s 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. S� , d r ` Job Address _- V Q City Lot Size v� PM Owner's Name — `L✓�r� Address `) Phone 3� Contractor LJ W Address ,(-,r*-- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑• PUMP INSTALLA N ❑ SYSTEM REPAIR Q OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTIONS CATIONS 0 Industrial ❑ Open Bottom ❑ Manteca ia. of W cavation Dia. of Well Casing + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of t Seal Type of Grout ❑ Irrigation �pprox. Dept Eastern Surface Seal all by Repair Work Done ❑ T mp H.P. Work Done Well Destruction Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IV 1No 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 TANKType/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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." nt us call r alr q i d inspections Ce drawing on reverse side. Signed X � Title: (Z- Date: Z � FOR DEPARTMENT USE ONLY Application Accepted by Date 3-c3-�-�7` Area Pit or Grout Inspection Data Final Inspection by Additional Comments: � -� T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ rac 835-fi385 Wt..5Q_. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952111 ' FEE AMtNTE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24IREV.ii85) Q ' EH14-28 .J 5♦ 6O INC,' t �