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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA `v® � � Telephone (209) 466-6781 c 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. i � k� \\ l LOwne ss —LSC Ud—l+&,Q VA City � Lot Size � Of3 PM + y �•(L, D ame h L Sh^.�L Address L �n82 t�lCtu+e Phone �r 3 i I 1 Se Address License No. Phone WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK \AG ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION CULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ MA Type of Casing Specifications ry� i'I Public ❑ Other elta epth of Grout Seal Type of Grout I (R� I I Irrigation —..Approx. Depth I 1 Eastern ! S ace Seal Insta led by _ V' ' NRepair Work Done ❑ Type of Pump _ `ai.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material top 50') Depth Filler Material (BI w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I'1 DESTRUCTIO Mo 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 depth of 3 feet: -- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line T� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance�to nearest: Well Foundation Property Line i SEEPAGE PITS I i Depth Size _ Number r SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 must call for all required inspections. Complete drawing on reverse side, �� igned X _ Title: __ _ Date: 4 l, FOR DEPARTMENT USE ONLY Application Accepted by CCL..w _ Q - — Date „d"d Area lJ , Pit or Grout Inspection by Date s F1 I Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369Z61 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE! AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. f ♦ EH 13-241REV.t/A5) �� CD V t � EH 14-2e x� Q 1