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i 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 Districts Job Address 1.�V v Cit Lot Size PM Owner's Name, '. Address, Phone 'Add Phoneq 4C&tiactor License No EPTYPE OF WLL/ UMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRlC T RE WELL ` OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEA ONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyype of Casing Specifications f Public F1 Other [❑ Deltaepth of Grout Seal 7ype of GroutI i Irrigation Approx, Depth l I Easteurface Seal Installed by ERepair Work Done ❑ Type of Pump State Work DoneWell Destruction ❑ Well Diameter erial itop 50') c Depth Filler Material (Below 501 r .. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION l l [No septic system permitted if public sewer is t available within 200 feet.► I Installation will serve: Residence Commercial Other ' Number of living units: f Number of bedrooms Character of soil to a depth of 3 feet: w - Water table depth t SEPTIC TANK ❑ Type/Mfg - Capacity, 1Y I No. Compartments PKG. TREATMENT PLT. ❑ t f �. � Method of Disposal Distance to nearest: Well Founds ion Property.Line 17-1LEACHING LINE . No. & Length of lines Tovi length/size W FILTER BED ElDistance to nearest: Well undation Zd. Property Line —V:4- k SEEPAGE PITS 11 4 Depth siz 6- N4nbar SUMPS Cl Distance to neo est: Well' Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accor6nce 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 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." i The appGcan dust call=spections, Complete drawing on reverse side. /] i Signed X Title: �.. Date: FOR DEPARTMENT USE ONLY Y Application Accepted by Date 4(T2 W Area t or Grout Inspection by Date Final Inspection b1r I }�i/cu�'�—i�� Date d Additional Comments: E D Stk,, 466-.67817 -O.Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 e, x 1 Applicant- Return all`copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,, CA 95201 r' INV. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE{ PERMIT'NO. i u e ♦.EA 53.24{REV,1./n 5) EK 1426 � ii�