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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON 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 City Lot Size PM Owner's Name Address — Phone P �y� � I Contractor&d,4 AddressIA5 [.' i �License 144&�Phone TYPE OF WELL/PUMP: a NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �INE,FOUNDATION AGRICULTURE WELL OTH PITS/ INTENDED_ USE TYPE OF WELL PROBLEM AREA CON STR SPECIFICATIONS x ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack y Type of Casing Specifications f I Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout l Irrigation pprox. Depth I i Eastern Surface Seal Installed by - p Repair Work Don Type of Pump' H.P. State Work Done T We11 Des ion ❑ Well Diameter J Sealing Material (top 50'I Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION l 1 DESTRUCTIO INo septic system permitted if public sewer is ` 3 available within 200 feet.) Installation will serve: Residence_ Comrimercial_Oihef Number of diving units: Number of bedrooms Character.of'soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No!Compartments PKG. TREATMENT PLT. ❑ a , � NletFiod of Disposal Distance to nearest: Well '4 o undation Property Line 1 LEACHING LINE D No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ r 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. t 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 applica must call for all required inspections. Complete drawing onreversAsid Signed Title:./� M � �� Date: FOR DEPARTMENT USE ONLY + Application Accepted by date 6 �7 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE I , INFO �AyMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH1324 IREV.i i H 51 EH 44-28 e -