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rtJ <.� 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 N Local Health District. ,r. f 2© 'Jcdd I . . Job Address City Lot Size � PM > [ Y_> Address 2- Phone Owner's Name r I--- 4 I Contractor Address 26Adm. Alow. License No- Phone — TYPE OF WELL/PUMP: U NEW WELL,`v, WELL REPLACEMENT )q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IIID'4 SEWER LINES DISPOSAL FL01604- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL: PROBLEM AREA CONSTRUCTION SPECIFICATIONS r E] Industrial ElOpen Bottom t E3Manteca Dia. of Welk Excavation Dia. of Well Casing Domestic/Private Gravel Pack 19 Trac T of Casing >0 VI, Specifications � (� Y Type !3 ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal R Type of Grit ❑ Irrigation --Approx.'Depth ❑ Eastern Surface Seal Installed by Repair Work Done t ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 a t Depth Filler Material (Below 501 PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r 4 available within 200 feet.) pC� Installation e: Residence Commercial_ Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments o i PKG. TREATMENT PLT. ❑ i 4 Method of Disposal J ' Distance to nearest: 7W7,ll t oundation Property Line LEACHING LUNE ❑ No. & Lengih'of lines �Iength/size_ FILTER BED ❑ Distance to nearest: Well Foundation I SEEPAGE PITS ❑ Depth Size Number SUMPS «, r-❑ 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 yin such-manner"as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin'g:,'.'I,certiN 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 alifornia."The applicant st call for,all._r quire inspections. Com let e drawing on reverse side. - a Signed X q i Date: f4 3 FOR PARTME T USE ONLY Application Accepted by �7 Date Area Pit or Grout Inspection by Date f Final Inspection by Date Additional Comments: ed"A eJ � — ❑ Stk 466-6781 El Lodi 369-3621 ❑-Manteca 823-7104 ❑ Tracy 835.6385 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 RECEIVED BY DATE PERMIT''NO. ' + EH 13-241REV.1/85) :—�� J * 4cs f�J �.��c a EH 14-26 17. _6