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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �J 1601 E. HAZE T ON AVE., STOCKTON, CA § Telephone (209) M. f PERMIT EXPIRES 1-YEAR FROM DATE ISSUED A (Complete in Triplicate) i Application is hepeby 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. f Job Address -SlCity Lot Size % 6EYpry r Owner's Name Address r Phone 0 3 Contractor •�r , rAddress mac! License No. �i 31'�7d '7 Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER W ITS7SUMPS INTENDED USE TYP L PROBLEM AUCTION SPECIFICATIONS ❑ Industrial p Open Bottom teca Dia. of Well Excavation --- Dia. of Well Casing ❑ Domestic/Private ack ❑ Tracy pe of Casin �- 9 Specifications l l Public ❑ Other Cl Delta.L Depth o Seal Type of Grout I I irrigatipApprox. Depth i I Eastern Surface Seal Installe } Repair Work Done ❑ Type of Pump `H.P. State Work Do Well Destruction ❑ Well Diameter.. Sealing Material (top 501 Depth 4--Filler-Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTI "septic system permitted if public sewer is s available within 200 feet.) 4 Installation will serve: Residence -Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` i SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ ` Method of Disposal ' Distance to nearest: Well Foundation Property-Line _ • a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I l Depth j Size , Number SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line }. 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 Dilirict. 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 following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion laws of California." , The apptica call for all requir d inspections, Co plete drawing onreverseside. Signed X Title: J��. . ... w Date: FOR DEPARTMENT USE ONLY Application Accepted by Dat Area Pit or Grout Inspection by Data Final Inspection by S Date G Additional Comments: A!v i pr ❑"Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 `-❑.Tracy_W5-6385.,,,,r _ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOONT REMITTED K INFO CA H RECEIVED BY DATE gRMIT NO. +.EH 1321(REV.1/K 5) aa EH 11-26 C] a J CAJJ/ �p �7