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r APPLICATION FOR PERMIT S j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 it PERMIT EXPIRES 7 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 r 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. Ir Job Address .7- 4 1</ - City S >G(llti Lot Size Ae F X JZ3 PM .i Owner's Name% Address Sri � i�G� �' — Phone Contractor Address License No. Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TASEWER LINES DISPOSAL FLD. ---P,ROP. LINE FOUNDATION AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type o ng Specifications ❑ Public Other ❑ Delta Depth of Grout Type of Grout ❑ Irrigatio --Approx. Depth ❑ Eastern Surface Seal Installed by ork Dane ❑ Type of Pump H.P. State Wo one_ Well Destruction ❑ Well Diameter Sealing Material {top 501 I E Depth Filler Material Melow 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of be Dams Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ od-vYaisposal "r Distance to nearest: Well a ionProperty Line LEACHING LINE Elngt No. & Leh es Total length/size FILTER BED ❑ Dista to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Nu ber SUMPS ❑ Distance to nearest: -Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andl, 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 ompensa�` tion laws of California." '' II The applicant must call for all required inspections. Complete drawing on reverse side. Signed)L e 1, 4;fAl 4 4:.grce. j— Title: Date: O FOR DEPARTMENT USE ONLY Application Accepted by LI Date Z� Area 03 d Pit or Grout Inspec'o b' Date Final Inspection by Date Additional CommZ500 0 5 I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca k3h104 ❑ Tracy 835-6385 M li Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 :i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE LPERMITV'NO.INFO + EH 13-2a IREV.i/95S :13 f EH 14-26 Q '