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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E 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. 16&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9'��/ Job Address - & Bku City Lot Size PM ` Owner's Name 1/_ �`�"� Address 3 Phone e6 "9 .J Contiactor 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 DISPOSAL FLD. PR 0JeF FOUNDATION AGRICULTURE WELL OTHER_W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ - Type of Casing Specifications Iw I'] Public H Other f ❑ Delta Depth of Grout Seal Type of Grout . I I Irrigation prox. Depth l I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Des on ❑ Well Diameter Sealing Material (top 501 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION l I DESTRUCTI i {No septic system permitted if public sewer is (� J available within 200 feet.) + v Installation will serve: Residence_F Commercial— Other Number of living units: Number of bedrooms € r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ ' Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line , 1 f i SEEPAGE PITS I I Depth I _ Size Number" SUMPS ❑ Distance to nearest:. Well Foundation Property. Line DISPOSAL PONDS ❑ t j 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-thavin-the-performance-of-the work for which this permit is issued, I'sfiall 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,1 shall employ persons subject to workman's compensa tion laws of California." The applicant must call tar all t"uired inspections. Complete drawing on reverse side. Signed X �( Title: Date: 1 G FOR DEPARTMENT USE ONLY Application Accepted by i Date . 27. Area I Pit or Grout Inspection by t to Fina! Inspection by Date Additional Comments / �� ss t 3a ' ❑ Stk 466-6781 ❑ Lodi 36 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 a IEEEO AMOUNT DUE ' AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. ``]] _ + EH 1 3-24(REV.1/85) �� t;,3[!' r 5/957 EH 14-2e � t �