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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTOIV AVE., STOCKTON, CA Telephone 12091 466-6781 "PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' a . (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 descri ed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City :TIAL ,� Lot Size PM Owner's Name �5-,<e ��'� Address ./Q"�IQ S. ��E7' F C. _ Phone Contractor �. Wl b AddressLicense No. Phone 44S _-?7/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T? DISTANCEJO NEAREST: SEPTIC TANK SEWER LINES ESPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ industrial d Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tf Type of Casing - ` Specifications I"I Public ❑ Other - Delta Depth of Grout Seal Type of Grout I I Irrigation _--Approx. th I 1 Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump1 H,P. State Work Done Well Destruction Cl Well Diameter! (Seating Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i l DESTRUCTION (No septic system permitted if public sewer is j t r� A f available within 200 feet.) (� Installation will serve: Residence s Commercial 'Other \n` Number of living units: Number of bedrooms .._ �. Character of soil to a depth of 3 feet: _ Water table depth I. SEPTIC TANK' ❑ Type/Mfg! Capacity , No. Compartments PKG.,TREATMENT PLT. ❑ + Method of Disposal Distance to nearest: Well Foundation Property Line # A + LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t � SEEPAGE PITS 11 Depth j Size Number r 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 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. Signed K r _ Title ' Date: F88 T_USE ONLY Application Accepted by Q Date "� 16 Area Pit or Grout Inspection by Date Final Inspection by r fid Date{I�f i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ? AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �: ♦ EH 13-21[REv.t/H s5 EH 14426