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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E. HAZE T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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: R O a f r Job Address - � � City• Lot Size Ctt s PM Owner's Name dl___ /i ! Address _ � 2 �� Phone Contractor Address License No. Phone ./�/GS� TYPE OF WELL/PUMP. v NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER E3 , DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DIS L FLD. , POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of:Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications F Public F1 Other 2 F1 Del ta.�._..�.�wDepth of-Grout-Seal Type of Grout I 1 Irrigation prox. Depth l I Eastern�_Surf ace-Seal.lnstalled by - Repair Work Done ype of Pump H.P. .y 4` State Work Done Well Destructs '"❑ Well Diameter Sealing Material [top 501 Depth Filler Material f I 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION,[ I INo septic system permitted if public sewer is available within 200 feet.l 4 Installation will serve: 'Residence'-Z#. Commercial'—'- Other Number of living units: Number o bedrooms Character of soil to a depth of 3 feet: + Water table depth j SEPTIC TANK Types Mfg Capacity* No. Compartments PKG. TREATMENT PLT. ❑__v f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE X No. & Length of lines �kUVTotal length/size c Q —� FILTER BED ❑ Distance to nearest: Well Foundation Property Line � I SEEPAGE PITS 1-1 Depth Size Number a — 1 ' L SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 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. i 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 nbt— employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature rn 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 copensa- lion laws of California." 'I The applicant must for I required inspections. Complete drawing on rev side. I $q Signed X - f a�` Title: " Date: / FOR DEPARTMENT USE ONLY Application Accepted by. &L (late �v 4 � � Area Pit or Grout Inspection b Date Finai Iction by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 6 5 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 BY DATE PERMIT'NO. INFO a EH134--24 IREV.1/8 5l28 ©.. ` .>a sJ !�1 4� �.1�.J�� j C:7 r •7� r EH 1v 7