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y ,1wa� APPLICATION FOR PERMIT # SAN JOAQUIN LOCAL HEALTH DISTRICT 5 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 C: �. 1"� ��3_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `� ~ Womplete 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 a ^` J City PM Lot Size `S Owner's Name Address % � Ca + C..� rO 5& __ _ Phone r ,Contractor Address Z e � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS r' INTENDED USE TYPE OF WELL PR LEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications i 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �Appr Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Ty hump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t'I REP AIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence CommercialOther Number of living units: � Number of bedrooms-1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK � 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O # Method of Disposal . t; ., _ w Distance to nearest: Well Foundation Property Line q l LEACHING LINE ❑ No. & Length of lines Total length/size "FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS ❑' Distance to nearest: Well Foundation 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 Di§trict. 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 ust all f all required inspections. Complete drawing on reverse side. q Signed X Title: Date: VA, FOR DEPARTMENT USE ONLY Application Accepted by Date Area L Pit or Grout Inspection by Date FiKal Inspection by Date J �8 Additional Comments: ____aa ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 i t FEE INFO AMOUNT DUE AMOUN�T`REMITTED CASH RECEIVED BY DATEE PERMIT N0. a.EH 13-24 IREV.1 i H 51 + 3�V� C X, EH 14-26