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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (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 'l City .L 1 W P Lot Size PM Owner's Name Address ! Phone Contractor K Address -M 5d �! V1 �License No. � X Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -.--.,PUMP.INSTALLATION ❑_ ___.,,,,,,__SYSTEM REPAIR 0. � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca "Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private fl Gravel Packt r ❑ Tracy4 Type of Casing Specifications ❑ Public ❑ Other e ❑ Delta —Depth of.Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth ❑ Easterri. Surface Seal Installed by Repair Work Done ❑ Type of Pump } H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 56 Depth i ' Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j7DESTROCTION []-(No septic system permitted if public sewer is ;}, available within 200 feet-1 ` Installation will serve: Residence L Commercial— Other �V ; Number of living units:J_ Number of bedrooms Character of soil to a depth of 3 feet: --4gfy _ Water table depth SEPTIC TANK Q Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. q Method of Disposal 1 Distance to nearest!��Well' 'Foundation Property Line LEACHING'LINE"" Nn:&'Length of lines """'total length/size .. z FILTER BED ❑ Distance to nearest: Well...- S-0r Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ .Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS 0 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 she..not employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or subcontracting 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 applicavn�t`"mu's't call for all required inspections. Complete drawing on reverse side. ` r Signed Date: a 7 s FOR DEPARTMENT USE ONLY Application,Accepted b — ' pp Y Date A P � rea 1 nI 1 # Pit or Grout Inspection by 'v Date Final Inspection by Date� _A F Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY \ DATE PERMIT`NO. + ili 13-24 EH 14-28(REV. 85) 1/