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�Q APPLICATION FOR PERMIT s. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 112091 466-6781 IPER MIT 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. p J� Job Address / f _� City Lot Size O � "PM Owner's Name, Address _.� -,9' ,/�?/N�r�JJ-��e Phone Contractor S I�� Address License No. Phone ` TYPE OF WELL/PUMP:.,, R NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ eR EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LDISPOSAL FLD. PROP. LINE FOUNDATION. GRICUL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EACTION SPECIFICATIONS❑ Industrial ❑ Open Bottom ❑ Manteca ll Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy sing - Specifications 17 Public ❑ Other ❑ Delta rout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern eal Installed byRepair Work Done ❑ Type of PumpH.P. � State Work Done _ Well Destruction ❑ Weil Diameter Sealing Material (tap 5011 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I. DESTRUCTION I iNo septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence #- Commercial— Other' -- IIF Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg 1_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS Ll Distance`to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ �T 4 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 shalt 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: "1 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." f: The applicant must call or.all required-1h pec' ns. Com to drawing on reverse side. - l ! 7 Signed.X .�.�–+ Title: �% 7 /�/ -- Date: /�� l - ' FOR DEPARTMENT USE ONLY Application Accepted by v _ Date 'Z Area f If Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: oe AZ ~ ❑ 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 f Y FEE AMOUNT DUE:t AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT NO. {n/ + EH 13-24(REV.ti65) INFO � r��A -1,51,�ezl EH 14-26 - - }