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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �o 6Z<11r,,!/Z. L @ f Job Address _1_0 rl icy�lrsLot Size PM Owner's Name Address'_ Phone / / Contract Address Address � �� License Not Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WE RE AGEMENT [J DESTRUCTION ❑ PUMP INSTALLATION ❑ Y TEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — SEW4LINE _ DISPOSAL FLD. PROP. LINEFOUNDATION _ AGRIWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ASTRUCTION SPECIFICATIONS❑ industrial ❑ Open Bottom ❑ Mantecaof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy ype of Casing _ Specifications 111 Public r Other n Delta Depth of Grout Seal Type of Grout I ! litigation —,Approx. Depth t 1 Easter/ Surface Seal Installed by - Q Repair Work Done ,O Type of Pump H P __—____ State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material itop 501 ----- - Depth Fiiler Material(Below 50'1 — - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 Leet.) installation will serve: Residence vCommercial_ Other Number of living units: Number of bedrooms �-3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type%Mfg Capacity'' No. Compartments PKG. TREATMENT PLT.C ? +�L Method of_Disposil Distance to nearest: Well" Foundation ( .Property Line r . LEACHING LINE Cl No. & Length of lines /�t•�� `Total iength/size Y FILTER BED ❑ Distance to nearest: Weil /-�= Foundation11tS1-- Property Line W 7 . SEEPAGE PITS 11 Depth Size Number i SUMPS 1' Distance to nearest Well Foundation-40649 Property Line DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature cartiftes 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 taws 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 Personsbubject to-workman's\o hsa- ' tion laws of California." 1 1 The applican ust call for required upections. Complete drawing on reverse side. C JV, Signed X Title: / Date: F R DEP RTMENT USE ONLY �,,f 1 Application Accepted by Date �" Area Pit or Grout Inspection by Date Final inspection by Date 13-Fa Additional Comments. ---- C1 Stk 466-6781 L7 Lodi 369-3621 ❑ Manteca 823-71104 ❑ Tracy 836-6385 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 CASH CK RECEIVED BY DATE PERMIT-NO. . EN 13MIIiEV- ia5wINFO —? EN 14-25