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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �11! ff Telephone (209) 466-6781 1I PERMIT EXPIRES S'YEAR FROM DATE ISSUED (Complete in Triplicate)p p i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des ribe . his application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 6 O ..m City Z g?/__2 Z W Lot Size Z 7 X /2 Q PM Owner's Name Y /`rrJ1 s! dlrl�S Address � d t� Y G7 Phone 4//-/ Contractor ? Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDA ON AGRICULTU ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF L PROBLEM CONSTRUCTION SPECIFICATIONS, j ❑ Industrial ❑ Open Bottom ❑ eco Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing ' Specifications F1 Public Cl Other elta Depth ofGrout Seal Type of Grout 11 Irrigation --Ap ox. Depth l l Ea ern Surface Seal Installed by `- - Repair Work Done LlTyp of Pump P. '• f State Work Done t h Well Destruction .❑ Well Diameter S ling Material (top 50'1 Y Depth Fille Material IBelow 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1 DESTRUCTIONY INo septic system permitted if public sewer is ' available within 200 feet.l Installation will serve: Residence— Commercial_ Othef Number of living units: Number of bedrooms f 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 Q� , LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f t� SEEPAGE PITS ( I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line . i DISPOSAL PONOS ❑ p 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 Y employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." The applicant must call for all required spections. Complete drawing on reverse side. Signed X Title: Date: 1 2 - --- FOR DEPARTMENT USE ONLY J Application Accepted by _ __ Date Area l/ Pit or Grout Inspection byDate Final Inspection by Date�� Additional CommentsAA 3 ❑ Stk 466-6781 ❑ Lodi 369-3621 -EI 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 CASH RECEIVED BY DATE PERMIT'NO. INFO a.EH 13-2441REv.II1151 EH 14-26