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i APPLICATION FOR PERMIT 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) 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. Jab Address 2 9 City ' Lot Size PM"' c , . ' Phone Owner's Name ress � - rn Contract,)r �dress � License fVo.��Phone Jl 7y S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � fi Z PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP, LINE FOUNDATION - A (CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR N{AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ teca Dia. of Well Excavation .. bio. of Well Casing ❑ Domestic/Private �❑�Gravel Pack Tra Type of Casing Specifications i`1 Public l I Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation --Approx. Dept l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work bone_ Well Destruction ❑ Well Diameter Sealing Material (top 501 ` ___. ! ,'N Depth Filler Material (Below 50') f TYPE OF`SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION i I DESTRUCTION l I Wo septic system permitted if public sewer is E y ✓ available within 200 feet.) n } Installation will serve:' Residence_ Commercial Other t �1J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg a Capacity/ No. Compartments PKG. TREATMENT PLT. ❑�. w �`ry ,� e Method of DOs I Distance toy nearest: Well� Foundation_ Property Line /+ LEACHING LINE ❑ No. & Length of lines �Totalengthyize' S FILTER BED ❑ Distance to nearest: Well FoundationtProperty Line L1 JJJ. SEEPAGE PITS I 1 Depth Size ' Number c^� SUMPS L-I Distance to nearest: Well _ Foundation" r Property Line J DISPOSAL PONDS-^ -C] h 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, a I 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 n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f ` certifies the following: "I certify that in the performance of the work for which this permit is issued,Fshall employ persons subject to workman's compensa- tion laws of California." Thea pplicant ust call for al required inspections. Complete drawing on reverse side Signed X r 7 Title: Date: U — l FOR PARTMENT USE ONLY C� l II .� Q J `-' Area i f Application Accepted, by Date `' Pito Grout Inspection by } - t Date 6 �Finai Inspection by_ Dated Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE A OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.1/85) 0-0 tom_ f/ r0F.0— EH 14-2e