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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 11,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 Regulatio s of the San Joaquin Local Health District. f 1 Job Address �t L City. Y Lot Sue PM D / Owner's Name Pen,, �` .4 f f onAddress Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION D PUMP INSTALLATION O SYSTEM REPAIR 11 OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (` INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom'- 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- -Type of Casing Specifications M Public n Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation --Approx. Depth I I Eastern Surface Seal Installed.by. - Repair Work Done O Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I"1 REPAIA/ADDITIONfr DESTRUCTION I I (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 dept of 3 feet: MO Z--A-g �`_'"� _ Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ?_ Method of Disposal Distance to nearest: Well Foundation Property Line . ACHING LINE _ No. & Length of linesTotal length/size I FILTER BED D Distance Ito nearest: Well fn Foundation: Property Line SEEPAGE PITS I I Depth '-I Size mber ��Distarice to:nearest: Well��Q_ 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m clu r ctions. Complete drawing on reverse side. + Signed 40t� Title: Date: 1 `� FOR DEPARTMENT USE ONLY Application Accepted by ►�---- Date Area Pit or Grout Inspection by Date — Final Inspection bqJda Dat Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pem►it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM UNT REMITTED CASH RECEIVED BY - DATE PERMIT'NO. INFO S r/ + EH 13$1 tREV.1 til F"1A.28aae a�x