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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ppYME ED 1601 E. HAZE T ON AVE., STOCKTON, CA BEGS Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP (Complete in Triplicate) NMti+N�p,\�I HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theork,f�@ip , d� made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules n Regu ations of the San Joaquin{Ts application is Local Health District. Job Address City.� Lot Size PM Owner's Name Q rC1'1/1 Address 30 Phone Contractor 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 ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL THER WELL -r((� PITS/SUMPS INTENDED USE TYPE OF WELL' ' PROBLEM'AREA�"'CONSTRUCTIOiV SPECIFICATIONS " it ❑ Industrial L) Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1�Q Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications f"1 Public El Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth p I I Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump o H.P. State Work Done Well Destruction ❑ Well Diameter �� Sealing Material Itop 50'1 Depth—L Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is 4 available within 20D feet./ - Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments y n f PKG. TREATMENT PLT. ❑ Method of Disposal V+4 Distance to nearest: We Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation' Property Line ,■ _. DISPOSAL PDNDS"� ❑ A...`�.` .� Wi=t .. -•= — �- . — *r . 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 rrltlSt call for all required inspectio S. Complete drawing on reverse side. Signed X r fd Title: Date: y ORD PARTMENT USE ONLY Application Accepted by Date (n� Araa I Pit or Grout Inspection t Date Final Inspection b Date Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 u 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 CA H RECEIVED t3Y PATE PERMIT NO. +.EH13-24IREV.ri1i5) EH142t1