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APPLICATION FOR PERMIT SAN JOAO,UIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA P 1 Tele hone (209) 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) a 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 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. , I Job Address O ct, -� City "— Lot Size/00 l_ PM -jam _ p . -r- P e q�vner's Name �r - �� Address '�o (�' 'L 'T� Phone t i Contractor Address License No. Phone F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P MP INSTALLATION ❑ SYSTEM REPAIR [IOTHER ❑ r DISTANCE TO NEAREST: SE ANK SEWER LINES DI AL FLD. PROP, LiNE FOU NDATIO AGRICULTURE WELL ER WELL PiTS/SUMPS INTENDED USE TYPE OF WELL PR AREA CONSTR N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications ❑ Public ❑ Other ❑ a Depth of Grout Sea Type of Grout ❑ Irrigation ---Approx. Depth Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pum H.P. State Work Well Destruction ❑ Well Di eter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI N o septic system permitted if public sewer is vailable 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size p: FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ - 4 I hereby certify that I have prepared this application and that the work will be done in accordagce 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 fcertifies 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 inspections. Complete drawing on reverse side. Signe + _; Tiile: A Date: Qftigi EPARTMENT USE ONLY Application Accepted by T Ackl!.N INA rs Z Date -�� Area ._ Pit or Grout Inspection by Date Final Inspection by g<_ � Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 iFEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED SY DATE PERMIT"NO. + EH 13-24 4REV.i/a 5) Ca� ,m EH 1426 �J – . - `-- —, �7/O`7 197-76 1