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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA Telephone (209) 466-6781 _ 3V+o PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NCO (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is f 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 Sari Joaquin Local Health District. '" 3 Job Address 3 y0 fir !N �3 JCity 57� � 4 Lot Size/ PM ' Owner's Name C ` +`" ddress �` � Q - Phone Contractor �' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER "❑ t} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE lvjU i FOUNDATION AGRICULTURE WELL 0TH PITS/SUMPS p INTENDED USE tTYPE OF WELL PROBLEM AREA TION SPECIFICATIONS ❑ Industrial 11 Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ ❑ Delta Depth of Grout Seal Type of Grout Ii ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by i Repair one EJType of Pump H.P. State Work Done 6 Well destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material {Below 501 II TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is x 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 X 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 " SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line - Y 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." 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 jaws of California." T plicant must all fo I spections. Complete drawing on reverse'side. - - �1/y"/ � Sig ed Title: Date: FOR DEPARTMENT USE ONLY Q Application Accepted b " /"' _ Date — 6-u Area Pit or Grout Inspection Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3&3621 ❑ Ma ca 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 f 41 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMITNO. INFO �j nn JLA�—k7 + EH 13-24fpEV.rin51 �� •o{,� L`v 1 197— EN 14-28 .. ._ .--..._..... .. 1 _ i