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APPLICATION FOR PERMIT . - FS II SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ., 1, , . (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 I 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. • '/TI+�ICI� Cit Job Address y �Lat Size PM Owner's Nam. CCJtii 1+W Address / T7` - r [ i�/Cle V Phone ��&S Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ = SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR SEPTIC TANK SEWER LINES DISPOSAL FLD. RR-6P. LINE FO N AGRICULTURE WELL OT HE PITS/SUMPS INTENDED USE TYPE OF WELL P AREA CONST SPECIFICATIONS ❑ Industrial ❑ Open Bottom�.. ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications D Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation —4 Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (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 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number SUMPS ❑ 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 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 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." , Thea Gca u call for all re fired inspections. Complete drawing on reverse side. Signed Title: D/V�� Date: -7 tFO EPARTMENT USE ONLY ry Application Accepted by Date i Area 7�r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 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 RECEIVED BY DATE PERMIT'NO. INFO r CASH �j + EH 1142e 3-24(REV.iiN5) EH ©� 3S. 00 r„lj2 ,--27_ "I 7 � —q9 '