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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. G Job Address City . Lot Size .04 Owner's Name Address Phane�.,w' 1� Contractor's Name License Na. Z.2Phone�� TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ O PUMP INSTALLATIONlieSYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTI NK SEWER LINES z- DISPOSAL FLD,4;2L* PROP. LINE} " " FOUNDATIONAGRICULTURE WELL `'"' OTHER WELL . PITS/SUMPS,4W k F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private LJ Gr-a-v-'Pack" -'-""'^p-1YaCy {;yype.a& dg ,s. ecifications Q Public ❑ Other ❑ Delta Depth of Grout Seal T ' ype of Grout` ❑ irrigation --Approx. Depth Eastern Sura a Seal installed by aeoair Work Done Type of Pump H.P. State Work M e Well Destruction ❑ Well Diameter r Sealing Material Stop 501 - ~ Depth r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if py -c sewer-is l available within-200 feet-; ^� Installation will serve: Residence_ Commercial_ Other 15 Number of living units: Number of bedrooms t. Character of soil to a depth of 3 feet: - Water table depth Q� SEPTIC TANK ❑ Type/Mfg r - Capacity No. Compartments #- PKG. TREATMENT PLT. ❑ Method of Disposal Disiance'to'nearest: Well, ' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundati Property Line SEEPAGE PITS Q Depth Size - Number SUMPS Q Distance to nearest: Well Foundation_ Property Line ti DISPOSAL PONDS ❑ _ hereby certify that! have prepared this application and that t work will be"one in a ordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i.I t Home owner or licensed agent's signature certifies the followin : "I.Certify-tha n'the-pe rmance of the work for which this perrgi is issu,,ed, I shall not employ any person in such manner as to become subject to wo man's com`pe sation laws of California." Contractor's hiring or sub-contractin gnature certifies the following:"I certify that in the performance of the ork for which t is permit is.issued-„ shah errtploy p�rso-__-ns subfect to workman's compensa- tion laws of California.” J The applicant must call for all re d inspections. Complete rawing on reuse side. Signe ills: Date: n FOR DEPARTMENT USE ON Y Application Accepted by Date Area Pit or Grout Inspection b pe y Dat /Final Inspection by Da Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6 Applicant- Return all copies to: Environmental Health Permi /Services 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT,REMITTED INFO CASH �RECEIVED BY ,r - DATE--.,, PERMIT`N0. T j + EH18-24 1REV.10/83F * #�." 4-26 EH 1