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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA 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 _OOJ3 -10440� City Lot Size PM Owner's Name //�/ ✓ / Address Phone Contractor �Q 9� Address License No.-3 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SIPIAIER LINES DISPOS PROP. LINE FOUNDATION AG (CULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AEA CONST ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecaof Well Excavation Dia. of Well Casing ❑ Domestic/Private L1 Gravel Pack ElTracy Type of Casing Specifications i'1 Public 17-1 Other ❑ Delt Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eas nurface Seal Installed by Repair Work Done L-1Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Sealing Materia top 50'1 Depth Filler Material (Belo 50') z TYPE OF SEPTIC WORK: NEW INSTALLATION XT R£PAIRIADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: --4— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth UJ SEPTIC TANK tV Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �.— Method o1 Disposal ( �, Distance to nearest: Well � Foundation Property Line r LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well j O O FoundationC Property Line SEEPAGE PITS I I Depth Size Number SUMPS C 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 laws of California." The applicant m all for ail re r9Inspections. Complete drawing on reverse side. Signed X // _ Title: Date: G CJ's' �1?�, FOR DEPARTMENT USE ONLY Application Accepted by Area a Pit or Grout Inspection by Date___ Final Inspec ion by Date wl� Additional Comments; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 FEEINFO '`MOUNT QUE AMOUNT REMITTED C SH RECEIVED BY GATE PERMIT N0. + EH 13- (REV.riH51 F70e EH t4-2t3M