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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Address2SSSI A, City t Size ^^7 I Owner's Name ' Address / /, Phone Contractor ^ ddres`s S '.G /l3 License No./ �✓� Phone / V --+ 2_Z } TYPE OF WELL/PUMP: rNEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE # a I FOUNDATION AGRICULT RE WELL. OTHER WELL PITS/SUMPS r 4 INTENDED USE TYPE OF WELL PROBLEM AREA ONS UCTfON SPECIFICATIONS , ❑ Industrial ❑ Open Bottom E71 Manteca of Well Excavation Dia. of Well Casing ¢ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications 171 Public fl Other Cl Delta D th of Grout Seal Type of Grout .' I I Irrigation --Approx. Depth 1 I Eastern S ace Seal Installed by Repair Work Done ❑ Type of Pump P. �' State Work Done 4 G Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) s Installation will serve: : Residence Commercial_ Other Number of living units:. o Number of bedrooms Character of soil to a depth of 3 feet: on A Water table depth SEPTIC TANK ❑ TypelKV19 "Dr Capacity No. Compartments PKG. TREATMENT PLT" L] LL Method'of-Disposal Distance to nearest: Well T Foundation y Property Line V 0.d LEACHING LINE ❑ No. & Length of lines a+ Tota! lengthlsize FILTER BED © Distance to'nearest: Well Foundation u Foundation _ n Property Line v OL S PITS I I' Depth lie LIMPS Distance to nearest: Well Foundation Property Line 1�/ ❑ D AL PONDS c 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 Diktrict. 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 x employ any person in such manker.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." 7 The applicant ust call for required " spections. Complete drawing on reverse side. Signed X Title: Date-, FOR DEPARTMENT USE ON& A i Application Accepted by j Date ` 7 Area , S { Pit or Grout Inspection by '":; Date Final Inspection by Dat 2'� 4 Additional Comments: ❑ Stk 466-6781 ` ❑ Lodi 369-3621 'D Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Returh all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EF'OAMOUNT DUE AMOUNT REMITTED C HRECEIVED BY DATE PERMIT"NO. EH 13-2/(REV.I K 5) ....y 0-.-�'� �� U P�U_� C� EH,/-2a /