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�s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-67$1 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' I'I (Complete in Triplicate) # .Application isherebymade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is ! is r 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. bo Job Address City Lot Sized ' PM Owner's Name AddressR ` Phone Lk ` Contractor Address License No. Phone 1'F TYPE OF WELL/PUMP: NEW�WEL.L ❑ 1iVEL'LIREP,LACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ "'� OTHER ❑ _ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP.OSA FLD. PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca "` Dia. of Well Excavation Dia. of.Well Cosi' g n El Domestic/Private El Gravel Pack r El Tracy 111'�, Type of Casing`24 Specifications _ s ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑Type of,Pump .- --el H.P. t State Work Done a - Well Destruction ❑ -Well`,Diameter �Si aling Material (top 501 LE Depth - Filler Material (Below 50') TYPE OF SEPTIC-WORK:-NEW INSTALLATION-01"REPAIR/ADDITIO W 'DESTRUCTION ❑ (No septic system permitted if public sewer is Vy v r�� available within fee 1 Installation will serve: Residence_I Commercial— Other 't r Number of living units: Number of bedrooms a f ervu v .` Character of soil to a depth of 3 feet:` - Water table depth �9 SEPTIC TANK Type/Mf Capacity) No. Compartments I PKG. TREATMENT PLT. � [J 4 Method of Disposal Distance to neo st Well foundation Property Line400 . LEACHING LINE No. & Length,of lines T tal length/size 'O"00•4Y-Mo. xF r: lie FILTER BED ❑ Distance-to -are W li lG i! Foundation� Property Line �7i d Or- 615 b SEEPAGE PITS ❑ Depth " Size Y r �Numbdr R SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL„PONDS_�..0. I hereby certify that I have prepared this application and thatAhe work will be-dbne inraccordance'.with San JbaquO(566nty ordinances, state laws, and *I' ar�Y art W y rules and regulations of the San Joaquin,Local Health D"istnct: i V- T Yr ' 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 k certifies the following: "1 certify that in the'performance oftherwork-forOhiGh this peimifis issued7,1 shall eoi�t mp°loy persons-subie6 workman's compense- ' tion laws of California." 4lEa: yl .40 ++� The applicant s call for all re Ir Ins onS Complete drawing on reverse side. t (� r Signed X Title: � Date: l `-' FOR DEPARTMENT USE ONLY Application Accepted by Date ,, 6 Area Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 85 Applicant- Return all copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED INFO H RECEIVED BY DATE PERMIT`NO. + EH13.241REV.1/a5) -7�, I EH 14-26 C3,:. k7 F7 �� L6_1 � I I ]