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` l APPLICATION FOR PERMIT c SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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.. C �[ 25 a- � w 0.S Cit S�Oel� av Lot Size PM Job Address Y 3S� Cy Owner's Name U a� ►C��IQN {dress C7 c ]Phone Contractor S� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS �} INTENDED USE TYPE OF WELL PROBLEM AREA__LaNTTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing C ' ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications f'l Public fl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I ) Eastern Surface Seal Installed by _ I Repair Work D Type of Pump H.P. State Work Done We ruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 7 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION [ I 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 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 I SEEPAGE PITS Ii Depth Size Number SUMPS L-1 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." T licant must calf far all required inspections. Complete drawing on reverse side. l� 41l r, Signed Title: ._ ^ Date: FOR DEPARTMENT USE ONLY l ! Application Accepted by / ` Date ` ' Area Pit or Grout Inspection by Date _ 'nal Insnectinn by80 CL4* Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy -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 CK RECEIVED BY DATE PERMIT NO. INFO ��yy �] OCASH C-�j�n + EH 13-244HEV.1/85) `Y' _ CA , "'1oc -, EH 14-26