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APPLICATION FOR PERMIT ~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., 5TQCKTON, CA it Telephone (2091466-6701 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) the rk is cation is Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install nd the R o s and hereinR Regulationsofof the San y Joaquin i made in compliance with San Joaquin`County Ordinance No. 549 for sewage or No. 1862 for well/pump Ip LAdd2j�M4 lh Districtr -- �` vV� �l �"JLat Size PMCityt� qy��` �(Phone/ AddressLicense No._.-----PhoneF Address DESTRUCTION ❑WELt REPLACEMENT ❑MP: NEW WELL ❑ OT PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DIS D. PROP. LINE SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL 1 FOUNDATION 1 3' ONSTRUCTION SPEGFICATIONS INTENDED USE TYPE OF WELL Pf1013LEM AR Dia. of Well Casing ( ❑ Open Bottom ❑ eca Dia. of Well Excavation ❑ Industrial . . � Type of Casing Specifications ❑ DomesticlPrivate D Gravelf ack ❑ Tracy yp Type of Grout Oth ❑ Delta Depth of Grout Seal 1 M Public Surlace Seal installed by I I Irrigation --Approx. Depth t I Eastern State Work Done Type of Rump �--- H.P. j Repair Work Do ❑ yp Material (top 50'! Welt Diameter Sealing k Well Destruction ❑ Filler Material IBelow 501 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIfilADDITION L 1 DESTRUCTION availableseptic w thin 200 if ppublic sewer is feet.) Other Installation will serve: Residences Commercial�— - v Number of living units: Number of bedrooms Water table depth E Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK D Type/Mfg Capacity__—� F � Method of Disposal PKG:TREATMENT PLT. ❑ Pro ert Line Distance to nearest: Well Foundation P Y Total lengthlsize LEACHING LINE ❑ Na. & Length o1 lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation tion y Size Number SEEPAGE PITS I I Depth Property Line SUMPS Ll Distance to nearest: Well Foundation ! DISPOSAL PONOS ❑ 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, an rules and regulations of the San Joaquin Local Health District. Hama owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannet as to become subject to workman's compensation laws of California." Contrace�sonshiring sub act to workman'ssub-contracting compensa- certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ p I ;ion laws of California." The apPllaws a f t c required ins etions. Complete drawing on re rse side. f. Title: Date: Signed X FOR DEPARTMENT USE ONLY fArea Date Application Accepted by i Pit or Grout Inspection byf.Date Final hs tion by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-362 ❑ Manteca 823-7144 .❑ Tracy 835-6385 Applicant - Return all copies to:Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CF,a RECEIVED 8Y DATE f ERMIY NO. FEE AMOUNT DUE AMOUNT REMITTED CASH Q pp INFO ((}} [/f[(/�J +.EH 1324{REV.r �� EH 14-2e