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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. �`� Job Address v City JLot Size PM .Owner's Name f Address y Phone Contractors Tt Address �/ 11�1.t�L, Qil�License N , / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ £ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR`❑ �. OTHER ❑ vDISTANCE TO NEAREST: SEPTIC TANK SEWE INES � DISPOSAL FLD. PROP. LINE t � FOUNDATION GR ULTURE WELL OTHER WELL �` PITS/SUMPS INTENDED USE TYPE OF WELL PROBL AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Man a Dia. of Well Excavation Dia. of Well Casing e ❑ Domestic/Private ❑ Gravel Pack ❑ Tr y Type of Casing Specifications f"1 Public n Othjr ❑ Ita Depkth of Grout Seal Type of Grout I Irrigation �_Approx. Depth i I astern Surface Seal Installed by Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 a , _Depth=- Filler Material'.(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 16 I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will-serve:' Residence Commercial Other Number of.living units: Number of bedrooms� i Character of soil to a depth of 31eet: Wates table depth SEPTIC TANK ❑ Type/Mfg Capacity--Z-16- No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispo al 14TDistance to newest:`.-_r Well Foundation��A./I Property Line 1 ,. (! 6� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ . Distance to nearest: + Well J Foundation 2 0 AL&Property Line SEEPAGE PITS I I Depth Size Number - SUMPS 0 Distance to nearest: Well Foundation Property Line 71 DISPOSAL PONDS ❑ 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 Di?atrict. - } Home owner or licensed agent's signature certifies the following: "I certify that in the performance bf 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 ust call for all required i spections. Complete drawing on reverse side. S Signed X r Title: Gl�[.L/7/t��C : Date: O k� 000or 000- FOR DEPARTMENT USE ONLY Application Accepted byDate 2 Area r f" `Pit or GroutHdspection by Date Final Inspection by rr G Date Q �� Additional Comments: e—tj 010 ,f7 ALO YJ i�_vi ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFFEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE �P}ERRMIT'NO. +.EH 13-24{REV. /+t 51 •�/� f /4 61 EH 1428 V