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f� APPLICATION FOR PERMIT '' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone �� ! 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin - / Local Health District. } Job Address City �4� � Lot Size PM `fieri L ( tel L byoi Mme_ a- _ Owner's Na e r Address Phone TYor Address .m License No. Phone_ e- PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL -WELL PITS/SUMPS INTENDED USE TYPE PROBLEM ONSTRUCTION SPECIFICATIONS Qom' ❑ Industrial ❑ Open Bottom eca Dia. of Well Excavation Dia. of Well Casing /tel ❑ Domestic/Private ❑ Grave c D Tracy of Casing Specifications I'] Public Cher {1 Delta Depth of Grou Type of Grout I ! Irrigation _._Approx. Depth { 1 Eastern Surface Seal Installed by Repair Work Done ❑* Type of Pump H.P. State Work Done Well Destruction ❑y Well Diameter Sealing Material (top 501 1 Depth t Filler Material {Below 501 _ TYPE OF SEPTIC WORK: yNEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other F Number of living units: Number of bedrooms Q 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 f LEACHING LINE „❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS I 1 Depth Size Number i SUMPS Ll 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 I 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. i�+ I A Si ned X_J� {l.� Title: �� Date: 9 (� ,.. FOR DEPARTMENT USE ONLY Application Accepted bdLi Date Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: E) Stk 466-6781 69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appiicant - 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 CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24{REV.i i N 51 EH 1428 �� '�� .� Y ,