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APPLICATION FOR PERMIT 1� SAN JOAQUIN LOCAL HEALTH DISTRICT Ptr 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 Distric4. v J ., . CI r �, Job Address �� ''` ` � tY Lot Size PM A �-- Address Phone IIIA �n 1 i1 Yy P, Owner's Name —h�A �y��L`ye �+�-��—r--- I Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSASLFLD PROP. LINE FOUNDATIO AGRICULTURE WELL 0 ELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA CONST N SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing " ❑ Domestic/Private ❑ Gravel Pack C1 Trac of Casing Specifications ❑ Public ❑ Other elta Depth rout Seal Type of Grout ❑ irrigationpprox. ❑ Eastern Surface Seal Ile by I Repair Work Done ❑ Type of P p H.P. State Work Done ' Well Destruction ❑ Well iameter Sealing Material (top 50') Depth- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L1 DESTRUCTIONX (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 j Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No Compartments PKG. TREATMENT PLT. C1 —Method of Disposal Distance to nearest: ell Foundation Property Line r (�LEACHING LINE ID No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: ell Foundation Property Line SEEPAGE PITS ❑ Dept Size Number' SUMPS ❑ "tance to nearest: . Well R ----.Foundation Property Line DISPOSAL PONDS I 1 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 tFie 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." nt mu call for I wired inspections. Complete drawing oh reverse side. Signed Title: Date: � e FOR DEPARTMENT USE ONLY Application Accepted by Date. -'ZG Area Pit or Grout Inspection by Date Final Inspection by; Data ��7 Additional Comments: ❑ Stk 466-6781 C7 Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO ` +7 + EH13-241REV.1/8-N 7 5s7-35iG EH 14-26