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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Pi �- Telephone (209) 466-6781 � 11PERMIT EXPIRES (YEAR FROM DATE ISSUED [ �? (Complete in Triplicate) 4I>✓ l Application is hereby made to the San J06 uin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Co{In Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 11 p Job Address �3u � °��'6 7V �v451 City s �� Lot Size+ !I �� PM Owner's Name Address 2 0r VIEVC Phone Contractor � Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLms SY5 M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION »A .ICULT. .E-W.ELL_.-.- - ...OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEEM A CONSTRl1CTIdN I5PECIFICATIONS ❑ Industrial ❑ Open Bottomnteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packcy a of Casing Specifications f'l Public C] Othera Dep of Grout Seal Type of Grout --- i I Irrigation -Approx.'.Dtern Surface Seal Installed by - Repair Work Done ❑ Type of Pump' `"H-P"" "� "" "-" ""State-Work-Donee Well Destruction � Well Diameter. Sealing Material (top�50')' i Depth 'Filler,Maierial (Below 50'1 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is E available within 200 feet.] Installation will serve: Residence Commercial_ Other Number of living units: __/_ Number of bedrooms It' ' Water table depth Character of sail to a depth of 3 feet: I' p SEPTIC TANK Li Type/Mfg ' Capacity No. Compartments `PKG. TREATMENT PLT. ❑ ,. . t 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 II Depth Size Number SUMPS E_l Distance ito 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 Joaquiri 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, !.shah employ persons subject to workman's compensa- tion laws of California." i The applicant mus II for all required 'nspec- late drawing on reverse side. tea Signed X_ f S;Title: vim' t✓/` ! Date: FOR DEPARTMENT USE ONLY - ,� v Application Accepted by Date rea Pit or Grout Inspectio ! Date Final Inspection by Date Additional Comments: liYYy k— � 1 I T Ld t� ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 vo )C-Wko o, fart'/ i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �r * i FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ♦ EH 13-241REV. EK 14-M