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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E.-HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r , ti - (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 ��0� : �� Y9a11/ t��SS _ City Lot Size PM- _. -- Owner's Name Address Phone y /� 0 �• Contractor's Name �• G License No. � ",V Phone TYPE OF WELL/PUMP, NEW.WELL 11WELL REPLACEMENT C1DESTRUCTION ❑ 4 `-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I —H.P. State Work Done ? Well Destruction ❑ Well Diameter r Sealing Material (top 501 Depth I Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION 9 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1e� available within 200 feet-/ �l Installation will serve: Residence--,L ;Commercial_ Other i. Number of living units: .,_i Number of bedrooms? Character of soil to a depth of 3 feet: #A aazV Water table depth i G SEPTIC TANK X Type/Mfg A Capacity No. Compartments PKG. TREATMENT PLT'❑ ( F Method of Disposal 5 Distance to nearest: Well O a • Foundation ."___ Property Line %•t ✓`~ LEACHING LINE +(` No. & Length of lines 3 � ' Total length/size In FILTER BED ❑ Distance to nearest: Well /50" Foundation /-f.' Property Line SEEPAGE PITS : ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line �M DISPOSAL PONDS r❑� 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 `mak`rules and regulat ons 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 cal for all required inspections. Complete drawing on reverse side. - i Signed 'tet Title: S Date: ,.y,• # q ��1--'_FOFt-DEPARTMENT USE Application Accepted by ri'?� `1 Date ��— Area 97 .--Pit or•Gyout-Inspection by Date Final Inspection by Date Additional Comments: �! ❑ Stk 466-6781 ❑ Lodi 369-3521 # ❑ Manteca' 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEENFO' .AMOUNT_DUE .�. -.—AMOUNTREMITTED. CK rCASH RECEIVED BY- - -DATE PERMIT-"NO, + EH 1324(REV.10183) LAc EH 14-26 '' -