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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 /��, /lr ,pi(Si' City Lot Size Q� PM '�� /�C�7 Owner's Name ✓r/ I f � /1 ^`Address Sy'� /�Z 4 � > Phone` Contractor '9Y ryry� '[ r`'""1 _ � Address�.7 L L.ice� nesse No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +PUMP-INSTALLATION,❑w" r SYSTEM REPAIR ❑ pT p❑ DISTANCE'TO NE,4RESVSEPTIC TANK" SEWER LINES"! DISPOSAL FLD. !NE 1 FOUNDATION AGRICULTURE WELL OTH Nem PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Type of Casing Specifications ❑Public Cl Other ❑ Delta Depth of Grout Sea! Typo of Grout ❑Irrigation x. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ pe of Pump H.P. State Work Done i4 e Well DestrucUo ❑. Well Diameter Sealing Material (top 50') ;j` t Depth Filler Material (Below 50') 1- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.) C Installation will serve: Residence L! Commercial_ Other Number of living units: Number of bed r R m~s��— Character of soil to a del of 3 feet: + Water table depth SEPTIC TANK ype/Mfg Capacity4 No. Compartments i PKG. TREATMENT PLT. ❑ Distance to nearest: Method of Disposal i Well Foundation Property Line 1 I I LEACHING LINE ZK No. & Length of lines —gel Foundation Total length/size FILTER BED ED Distance to nearest: Well" 1 YZ I �— --� Property Line_S � SEEPAGE PITS ❑ Depth l7 r Size_a)eldl Number SUMPS ❑ Distance to nearest: Well 464 _•Foundation Property Line DISPOSAL PONDS ❑ f it 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. ,ftl - fi Home owner or licensed agent's signature certifies the following; "I certify that in theperformance of the work for whithis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of, Californie.'� 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 11 shall em to tion laws of California." P Y persons subject to workman's compensa � * r The applica t st call fo re ired i ons. Com I to wing on reverse side. fi 1 1 - f + ..--�..r y i Signed Title: lct" Date: DEPARTMENT USE ONLY Application Accepted by DateZOJI!AArea Pitor Grout Inspection by Date Final Inspection by at -7 Additional e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 V Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO AMOUNT DUE a AMOUNT REMITTED CK RECEIVED.BY DATE ¢ PERMIT'NQ. t t EH 13-24{REV.1/n 51 EH 1426