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APPLICATION FOR PERMIT , xr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209)-46f3-65"4- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y (Complete in Triplicate) d Ir I. 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. LJobress � -- , _ City ST�G ✓Lot siz PM Name '�� Address �� _r PhanetorAddressLicense No. PhoneF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. ��"Jy x` UNDATION- AGRICULTURE WELL OTHER P175/SUMPS Y INTENDED USE TYPE OF WELL REAS CO N SPECIFICATIONS ELr 1 ❑ Industrial ❑ Open Bottom ❑ Mant Dia. xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing' Specifications FI Public Ll ❑ Delta Depth of Grout Seal a of Grout _ I Irrigation _-Approx. Depth I I Eastern Surface Seal installed by - Repair W one ❑ Type of Pump H.P. State Work Done h Well Destruction ❑ Well Diameter-1 Sealing Material Itop 50'1 xv1 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION'V Mo septic system permitted if public sewer is �. Z available within 200 feet.) \ Installation will serve: Residence_ Commercial_ Other _ 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 wl PKG. TREATMENT PLT. ❑ t Method of Disposal t Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line ! I � SEEPAGE PITS I I Depth Size# — Number SUMPS ❑ Distance to;.,rtgarest: Well+ Foundation Property Line j DISPOSAL PONDS ❑ , I hereby certify that I have prepared IN,s"appli6tion 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',)-lealtli District. .- Horne owner or licensed agent's signature,certifies thb following: "I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become Sublect 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 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 inspections. Complete drawing on reverse side. `C. Title: Date: Signed X / C i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or GroutA Inspection by Date Final Inspection by Date - _- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE i I AMOUNT REMIT-TEDCA RECEIVED BY DATE PERMIT"NO. + EH13-24 4REV.i/8 51 1 --agi EH 14.26 ✓ r '