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ESS' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED !i {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. c : rJobAddress i City Lot SizePM er's Name Address ,� �L �y`' Phone I Contractor_ �l� Address_ �� 50Y2J„ License No.7%7/60 -Phone d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [ THER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES SPO5AL FLD. PROP. LINE FOUNDATION AGRICULTUR OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS [D Industrial C1 Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing l ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications ❑ Public ❑ r ❑ Delta Depth of Grout Seal Type of Grout E] Irrigation _Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4k 31 Water table depth SEPTIC TANK X Type/Mfg 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: f well Foundation Property Line r 1. SEEPAGE PITS O Depth Number ! SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ " 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." Contractor's hiring or sub-contracting signature certifies the folio wi :"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 Calif.mi .' The applicant m t c I I squired inspections. Complete drawing on reverse siddeeJ. (Signed Title: tf _. Date: I �� ` A FOR DEPARTMENT USE ONLY n Application Accepted byDate7T l Area Pit or Grout Inspection Date Final Inspection b' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -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 INFO AMOUNT DUE AMOUNT REMITTED G RECEIVED BY DATE PERMIT'NO. + EHH 13-24 1428IpEV.1/8 5) 1 S ��5 �� U C jf�1-16701