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APPLICATION FOR PERMIT ��/` SAN JOAO,UIN LOCAL HEALTH DISTRICT � Q�'""'yf�� 1601 E. HAZE"TON AVE., STOCKTON, CA (((Ir �' Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED 1J�3 •' Ca*'y,� (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. 4' LU / Cit `��ui+tdt Size PM ddress yQ! Q� -� O D Phoner's Name A Address -actor--Z& Address License No. Phon 4 I OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENf ❑ DESTRUCTION ❑ PU P INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTI NK SEWER LINESDISPOSAL FLD. PROP. LINE k FOUNDATIO AGRICULTURE W OTHER WELL PITSISUMPS i INTENDED USE TYPE OF WELL LEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr a of Casing Specifications Cl Public ❑ Other Delta Depth o Type of Grout I I Itrigaiion —.-Approx. Dept l I Eastern Surface Seal Installed by - Repair Work Dane ❑ Type of Pump . H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1.1 DESTRUCTION No septic system permitted if public sewer is vailable within 200 feet.) I Installation will serwe: 'Residence_ Commercial 'Other ` ? Number of living units: Number of bedrooms . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal ~ Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size'M E FILTER BED ❑ Distance to,nearest:9 . Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 following: "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 law ifornia." / The ap Ica must call for all repo'ed,inspe Ion . Comple drawing on reverse side. / Signed itle: //LS�� Date: H tR =ARTMENT USE ONLY j { Application Accepted byA Date ~i ^07 Area 1 Pit or Grout�Inspecion by ate Final I ction by DateAdditionalta: L 0 Stk -6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385. t Applicant - Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 P FEE l INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. d + EH 13-21[REV.i/H 57 YY EH 14-24 1