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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 Fm (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 I 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. . 11 2 /rlL Leaf---A061 City Lot Size PM Job Address 9 Address License C Phone o Owner's Name /} Contractor's Name License No. C!0 81 2 Phone —II TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �b SEWER LINES DISPOSAL FLt]. PROP. LINE FOUNDATION -- AGRICULTURE WELL - = OTHER WELL - PITS/SUMPS - 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tn1 T ei of Casin P Specifications {�omestic/Private ravel Pack VcY YP g Q Public El Other ❑ Delta Depth of Grout Seal "5 - Type of Grout ❑ Irrigation �pprox. Depth Q Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done MP Material (top 501 Well Destruction ❑ Well Diameter 9 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q alvailao septic h tem permitted if public sewer is r Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ y Distance`to nearest: Well Foundation Property Line LEACHING LINE E3No. & Length of lines Total Length/size FILTER BED ❑, Distance to nearest: Well Foundation Property Line SEEPAGE PITS Q Depth f Size Number fSUMPS ❑ Distance to nearest: Well Foundation Property Line DiSPOSAL_P_ONDS_ _ O. 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work far which this permit is issued;I shall employ persons subject to workman's compensa- tion laws of California." The applicant 4ust call for all uire spections. Complete drawing o reve side. Signed 1 I Me; Date: F DEPART EN SE ONLY p Application Accepted by Date 6 a Area Q Pit or Grout Inspection by Date Final Inspection by Date I f Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 836-6385 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 CK# RECEIVED 6Y DATE PERMIT'N0. INFO CASH A-13-24(REV.10/83) �3��p. �-••�I- �� EH 14'28