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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1962 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address !� S7 /[p DS CityT---&C Lot Size PM Owner's Name Address I' d. (j r � }y Phone Contractor_/4 r.C, 0L [4n4;;e _Addressa-pi '� q�� TYPE OF WELL/PUMP: License No. / �� Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ 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 El Domestic/Private EDGravel Pack +. Dia. of Well Casing LJ Type of Casing ❑ Public 12 Other ❑ Delta Specifications Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Repair Work Done El Type of Pump . Surface Seal Insta�led by H.P. State Work Done I Well Destruction ❑ Well DiameterSea ling Material trop 54'1 Depth Filler Material (Below 50;) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DE STRUCTiON`L7'{Na septic system permitted if public sewer is S fnstaflation will serve: Residence available within 200 feet. _ � Commercial_ OtherCA 1 Number of living units:--- Number of bedrooms _ Character of soil to a depth of 3 feet: 1A SEPTIC SEPTIC TANK ❑ Type/Mfg 1 ! Water table depth Y'�i PKG. TREATMENT PLT. L7 Capacity� I No. Compartments.. Q ff ' Distance to nearest: Well r f t� �^ Method dir Disposal � t Foundation zV :Property Line ' . •. LEACHING LINE J;-"No. & Length of lines ll0 - Total.Jan th/size FILTER eD; ❑ Distance to nearest: Well � "'`-� I 'Foundation 4' Property Line iZOF SEEPAGE'P,ITS' ❑ Depth - , SUMPSNum er ❑ Distancetto nearest: VN'ell Foundation i DISPOSAL PONDS Cl Foundation Line 7& I hereby certify that I have prepared this application and that the work will be done in accordance with'San-Joaqu county ordinances, state laws; rules and regulations of the San Joaquin Local Health District. and 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 ofCali#or�ia.`Contractor's hiring or sub=contracting signature certifies the following:"I certify that in the performance of the work for which this permit is-iss Ce I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call fQIp all re fired i ctions. Complete drawing on reverse side. +� $ Signed � Title: i � Date: FOR DEPARTMENT USE ONLY ; Application Accepted by �� 7 Date Area Pit or Grout Inspection by DateFinal I nspection by Date Additional Comments: { D Stk 466-6761 ❑ 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 2949, Stk., CA 95201 1 . FEE AMOUNT DUE CK# ~ INFO AMDUNT REMITTED CASH RECEIVED BY DATE - PERMIT'ND. ..+'EH 1324.IREV.1/851 EH 14-26