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r. i y APPLICATION FOR PERMIT l� SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f�,b I (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 ___ Pho4&'s�� Contractor 6j-! Address h� Licensed Phon T� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL P l INTENDED USE TYPE OF WELL PR08LE CONSTRUCTIONwSPECEFiCli710N5 I y ❑ Industrial ❑ Open7Bottom anteca Dia. of Wel! Excavation Dia. of Well Casing { 171 Domestic/Private ❑ Grav s ❑ Tracy Type of Casing Specifications" FI Publicther` : 'g 171 Delta Depth of Grout Seal Type of Grout _ I I Irrigation __.Approx. Depth til ).Eastern Surface Seal Installed by _ { Repair Done 0 Type of Pump ' ' -'H.P. - State Work Done Destruction ❑ Well Diameter Sealing Material (top 50'1 �A Depth Filief'Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITION l DESTRUCT( (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial= Oiher'—_10- 1 Number of living units: Number of bedrooms r Charactevof soil to a depth of 3 feet. Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments l PKG.-,TREA"i'MENT-PL_T. ❑ "' Method of Disposal 1 - Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line I i - SEEPAGE PITS I 1 Depth, Size_ _ Number SUMPS L"1 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, and rules and regulations of the San Joaquin Local Health District. I 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 t 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." r - The applica ust call for all requRed inspections. Complete drawing on reverse side. g� I Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by � � Date � � Area il Pit or Grout Inspection _ D'ate ,t Final Inspection by. mFl�� Date Additional Comment • d ❑ Stk 466-6781 Q Lodi 369- 1 ❑ 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 INFO �JyAMOUNT DUE AM+�OU�NNTTRREEMrFrED CK RECEIVED BY DATE PERMIT N0. *.EH 1 3-24 1ttEH,1/H 51 EH 14-2e r L,J