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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE,' STOCKTON, CA •.Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ° t r (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 G �� J ' �� : ✓ City � C Lot Size PM G 9 Owner's Name f _ Address Phone ' Contractor �� ` Address, �OX V License No. J� 3�7' Phone t T WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES : IC TANK SEWER LINES DISPOSAL FLD. J1,�PROP. LINE FOU NDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private.;._—[]-Gravel.Pack ❑ Tracy Type o, V"N. w Specifications ❑ Public ❑ Other ❑•Delkj Depth of_Grout Sea Type of Grout a ❑ Irrigation ` i,'k -` pprox'Dep h� ❑ Eastern Surface Seal Installed by Jr j 1 Repair Work Done ❑ Type of Pump __..._ H.P. j State Work,Done_ ` Well Destruction -D--'W611-Dia tem e Ii----Sealing Miterial (top 50') ,� Depth j Filler Material (Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDIT40N -BESTRUCTiON-(!5"(N'o'tb`ptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other �11, Number of living-units:-=====--Nttmber-of-bedt't Drn �k Character of soil to a de of 3 feet: Water table depth SEPTIC TANK ❑ Type fAfg N Capacity No. Compartments ` PKG. TREATMENT PLT. 0 -�"'y Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE `X No. & Length of lines �` Total length/size 67f� ` I FILTER BED ❑ Distance to nearest: Well�S Foundation 40 Property Line SEEPAGE PITS w ❑ Depth " �- tSizeNumber �4 SUMPS ❑ Distance to nearest: Well Foundation Property Line k ` r DISPOSAL PONDS ❑ 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 follow_ ing: "I certify that in the performance-of the..work_for_which•this-permit-is-issued, I shall not employ-any'persorl'in'gu—dt nfanner as toto'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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must r• requ' ins ns. Complete drawing on reverse side. Signed - ' Title: Date:' FOR DEP TM NT USE ONLY I Application A capted by y Date �k AreaOF v - .�._ - ,. e Pit or Grout Inspection by i Date Final Inspection by Dat 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 CASH RECEIVED BY DATE PERMIT NO. ..ryryJJ INFO +SEA 13.24(REV.1/8 8) � EH 14-2a -cr,40.