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f APPLICATION FOR PERMIT SAN JOAQUIN LOCA. HEALTH DISTRICT S { 1601 E. HAZETON 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. / Job Address _E&6ff 7 ?� 1 '/ __ City Lot Size d BGG PM i / Owner's Nam Address s�T /,,e4,, � Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISFOS"AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ me Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack rac Type of Casing Specifications M Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ i I Irrigation ox. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Mat 'al (top 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size f� FILTER BED ❑ Distance to nearest: Well Foundation Property Line U SEEPAGE PITS l I Depth Size _ Number SUMPS Ll 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 DiWict. I 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." The applican ust call for all require inspections. Complete drawing on reverse side. Signe Tide: pa �� FOR DEPARTMENT USE ONLY Application Accepted by Date `� Area I0 Pit or Grout Inspection by Oate Final Inspection by Date Additional Comments: e (';\ --, a q "A ko ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all capias to: Environmental Health Permit/Service 1601 E. Hazelt n Av ., P Box 2009 Stk., CA 9520 INFO FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED By DATE E;PERMIT*NO.(REV.t iK 5) �EH 13-2el 6 Zd