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i APPLICATION FOR PERMIT Ea. S ; i SAN JOAQUIN LOCAL HEALTH DISTRICT No W4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 NQ r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED $ L, i (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. j. V Lot Size PM Job Address City Owner's Name Address . t4 Y Phone 11 Contractor'r/1X4_" License.NO Phone- - TYPE OF WELT./PUMP: OF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION ❑ SYSTEM R IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL.FLD. PROP. LINE= k FOUNDATION A RICULT WELL OTHER WELL- PITS/SUMPS INTENDED USE 4TYPE OF'WELL —PROBLE.- A—CONSTRUCTION SPECIFICATIONS w£ � s ❑ Industrial ❑ Open Bottom Cl tec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack Tracy Type of Casing Y Specifications ('1 Public Cl Other El Delta Depth of Grout Seal Type of Grout i I Irrigation .-Appro epth I 1 £astern Surface Seal In by Repair Work Done �❑ Type of mp H.P. R State Work Done _ Well Destruction;' ❑ Well iameter Seafin Material (top 50'1 Depth Filler terial (Below 50'1 -- TYPE OF SEPTIC=WORK: NEW INSTALLATION Cl REPAIRlAD (TION l 1 DE TRUCTION (No septic system permitted if public sewer is A within 200 feet.) Installation will serve: Residence_ Commercial— OtherNumber of living units: r. Number of bedrooms Character of soil to a depth of 3 feet;, er table dept SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments {� PKG. TREATMENT PLT. ❑ # i Method of Disposal I Distance to nearest: Well Foundation Property Line i ! t LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest:- Well Foundation Property Line r t ' r SEEPAGE PITS l 1 Depth Size - Number SUMPS ❑ Distance to nearest: Well Foundation% r 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. r 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,1 shall employ persons subject to workman's compensa- tion laws of California." ' p The applicant ust calf f required inspections. Complete drawing on reverse side. -- -z flu ' Signed X Title: Date: O EPARTMENT USE ONLY �? G, Application Accepted by Date `' `t 0 Area �V l r �30�Jl1 ' Pit or Grout Inspection by Data Final Inspection by - Date Additional Comments: �°�r G r' � r 10 C,k� i ❑ Stk 466-6781 IJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to:EnvironmentalHealtPermit/Services 16tH E. Hazelton Ave., P.O. Box 2009, Stk., E49501 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO GASH +.EH13-24 4REV.r/x 5) `D� � IN " EH 14-26