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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA w© Q Telephone (209) 466-6781. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a' (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District �7 tr Job Address �'/ C ,� City LS�t6CVI NLot Size PM Owner's Name � "�-�L Address _I�6 `�i /�E Phonee/G`5 �'ZIF 71K Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST L ON ❑ SYSTEM REPAIR ❑ OTHER ❑ d s, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.' FOUNDATION A LTURE WELL OTHER W PITS/ LIMP r , 1 INTENDED USE TYPE OF WELL PROBLEM AREA` TRU ECIFICATIONS -El Industrial ❑ Open Bottom ❑ Manteca o_ xcavation' Dia. of Wel!Casirig ❑ Domestic/Private ❑ Gravel Pack ❑ Trad Type of Casing Specifications ❑ Public ❑ Other elta Depth of Grout Seal`s Type of Grout ❑ Irrigation �4pprox. th ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Typ ump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 50'1 6 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No 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 A 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 tFILTER BED ❑ Distance to nearest: Well Foundation Property Line Y r SEEPAGE PITS }. ❑ Depth Size Number SUMPS ❑ Distance to nearest: well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. r 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,'1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections.'Complete drawing on reverse side. • 7 �f i/ S dd Title: "EZfLj Date: J / r ��ATM�ENTE ONLY r Application Accepted by Date— Area p Pit or Grout Inspection b Date Final Inspection by Date �� Additional Comment: ❑ Stk 466.6781 1 ❑ Lodi 369-3621 ❑Vanteca 823-7104 b fracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMET NO. INFO CASH + EH 13-24(REV.1/95) EH 1428 S