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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT : 1601 E. HAZE T ON AVE., STOCKTON, CA ! Telephone'(209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) j Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or,install the work herein descri d. 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. ��jj rpr, Job Address City & Lot SizeZ_J x —� - PM r Owner's Name rens ') J/ Phone J f ��,L._�_t7�� g / f / t � 7r�-MOL License 7z ! �i Contractort^ U Y® ddres License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL ER WELL ROP. INTENDED USE TYPE OF WELL PROBLEM AREA CON TION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac�ep ❑ Tr, -Type of Casing Specifications f Type of Grout f`i Public Cl Other Delta Depth of Grout Seal — I I irrigation —.-Appr I i Eastern Surface Seal Installed by - SV Repair Work Dane ❑ of Pump H.P. State Work Done Well Destructio Well Diameter Sealing Material Itop 50') Iv Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l ) DESTRUCTION l (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commerciai_ 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 r Distance to nearest: Well. Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Sire Number i SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 taws of California." The applica st call for all refire ns c'ons. Complete drawing on reverse sid Signed X Title: Date: I } FOR DEPARTMENT USE ONLY 2 ,Application Accepted b Date Area ©'+ I Pit or Grout Inspecti Date Final Inspection by Date F_ Additional Comments: t ❑ Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823 7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, StkrjJCA 95201 E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t EH 13-241REV,t/H5Y � EK 14-26 ••. I