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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/of 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,�;�, O4C .— Ci Lot Size '— D D PM Owner's Nam C /r/ Addre C'w2 �. Phone Contractor Address License No. Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P INSTALLATION El SYSTEM REPAIR LJ OTHER Ll DISTANCE TO NEAREST: SEP NK SEWER LINES _ .DISPOSAL FLD. PROP. LINE FOU NDATION AGRICULTURE WELL OTHER WELL SUMPS% _ INTENDED USE TYPE OF WELL PRO REA CONSTRUCTIO CATIONS t w a ❑ Industria( El Open Bottom ❑ Manteca a--or-well Excavation f Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type sing t I Specifications s El Public ❑ Other It Depth of Grou al Type of Grout ❑ Irrigation _.-Ap epth ❑ Eastern Surface Seal Instalfe Repair Work Done ❑ e of Pump H.P. St 1.to Work Done Well Destr ❑ Well Diameter Sealing Material (top 501 v} Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is !�...�.�,..d �. -'-�"'^""" available within 200 feet.) U) Installation will serve: Residence_ Commercial! Other Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet:"" 4 Water table depth !`1 SEPTIC TANK X Type/Mfg Capacity. 00 I No. Compartments PKG. TREATMENT PLT. Cl i ` � Method of Disposal Distance to nearest Well Foundation ! Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E1Distanceto nearest: Well Foundation Propp� Line SEEPAGE PITS ❑ Depth,. - Size Number SUMPS ❑ 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 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." Thea plicant t call fo all required inspections. Complete drawing on reverse side. , Signed Title: 'r Date, d FOR DEPARTMENT USE ONLY Application Accepted by Date :9- - U Pit or Grout Inspection Dat Final Inspection by Date 3 �` Additional Comments: / ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY rrr777 PATE PERMIT'NO. EH 1324(REV.1/H 51 R b EH 14-28 �i7-90