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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES TYEAR 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 d—(-4Z, ozD 5 !" City Lot Size PM Owner's NameA)A�,e� � dress � Phone Contractor cS'�,(�� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of ng Specifications FI Public ❑ Other - Delta Depth of Grout eal Type of Grout I I Irrigation --Approx. pth I ] Eastern Surface Seal Instailed-by Repair Work Done L7 Type of ump H.P. State Work Done 0 Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPA€RlADDITIO DESTRUCTION iNo septic system permitted if public sewer is available within 200 feet.)Installation will serve: 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS D 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 Diltrict. 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 corripensation 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 mu t call for all re it d in ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by4lo" Date 1 Additional Comments: Cl Y-)—Q ❑ Stk 466-6781 ❑todi 369-3621 ❑ Mantua 823-7104 ❑ Tracy 835-6385 4- Applicant Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. r.EH 13-14 iREV.t/)15) S Z EH 14-2a &!9t