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a �* < or APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA At,�z., Telephone (249) 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 Address �cj Q 2s - 4CJ /"tl7r/iF—�2 City a Lot Size PM _ A A Owner's Name Address �� Phone U 611. Contractor �:0—AA _Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. P INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0 s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEWAa IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of We ovation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy a of Casing Specifications 17 Public Cl Other f 1 Delt .Depth of Grout Seal Type of Grout I i Irrigation -r-_._Approx- Dept Eastern Surface Seal-I stalled by Repair Work Done ❑ Ty p H.P. State Work.Done Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITIO DESTRUCTION (No septic system permitted it public sewer is, r 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 SEPTIC TANK ❑ Type/Mfg T" 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance wiih"San Joaquin county ordinances, state iaws,..and rules and regulations of the San Joaquin Local Health District. 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, 1 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." The applica st call for all require inspections. Complete drawing on reverse side. Signed'X Title: D Date: �/� � FOR DEPARTMENT USE ONLY ( /�- Application Accepted by .�-- Date �' Area Pit or Grout Inspection by Date Final Inspection by Date U' Additional Comments: W61 7 Stk 466-6781 Lodi 368-3621 ❑ Manteca 3-7104 ❑ Tra% cy 56385 �' Ci plicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., A 001 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO + EH13-24(REV.i/n5) EH 14-26 !�