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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA w Telephone (209) 466-6781 [PERMIT EXPIRES 1,YEAR FROM DATE ISSUED d �I~ s (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 Co `nty 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 _ City Lot Size PM 7,11 Owner's Name — Address Phone /7 —51 Cbnt factor Address License No. Phone PE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN TA'LLATION ❑ SYSTEM REPAIR ❑ OTHER © s DISTANCE TO NEAREST: SEPTIC TA K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIO AGRICULTURE WELL OTH WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREAS STRUCTION SPECIFICA710N5 ❑ Industrial LJ Bottom anteca n 70e Wellxcavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tr g Specifications l`1 Public Ll Otfier Delta^n t Seal `Typeof Grout — 1.i Irrigation Approx.' th II Eastern nstalled by - Repair Work Done ❑ Type of p H.P. to Work Done _ Well Destruction ❑ VpIMiametef Sealing Material (top 50'1 -Depth °J Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTIOavlo septic syailable s stem rented d public sewer is Q) Installation will serve: Residence Commercial— Other Number of living units: Nurr&r of bedrooms Character of soil to a depth of 3 feet' Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l_") PKG. TREATMENT PLT. ElI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size h\ FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 1 I Depth Size Number SUMPS" L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 of 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 r ired "nsppktions. Complete drawing on reverse sideA Y.;. Signed.X _ Title: Date: FOR DEPARTMENT"USE ONLY �s -.-r�...M..-- -..,..,--�" Area Application Accepted by w F" r�.. � � Date Pit or Grout Inspection by Final Inspection by Datei'r Additional Comments: ' � 'C r ❑ Stk 466-6781 El Lodi 369-3621 © Manteca 623-71 ❑ Tracy 83 to-t?r�c� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 ' FEE , AMOUNT DUE` AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. , +.EH 13.24 IREV.t/A 5) "INFO •• '�" EH 14-26