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za APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA No G9 � Telephone (209) 466-6781 ' �J, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. N O-�^' ""� (Complete in Triplicate)s i i'? 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. " Job Address 149d9/ City , _- : Lot Size- PM i Owner's Name r GI e 2 ! SQ f7 Address (>G J�s'Y C` Q Phone 's I Contractor Address License No. Phone TYPE OF WELL/PU .NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1PUMP STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC NK SEWER LINES DISPOSAL FLD. PR INE FOUNDATIO AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA CONSTRUCTION SPECIFICAT \ ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Exc Dia- of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy asing Specifications (� ❑ Public ❑ Other ❑ Del Depth a ut Seal Type of Grout I ❑ Irrigation --4ppr6x. D Eastern Surface Seal Insta Repair Work Done 13ump H.P. State Done_ Well estruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION* (No septic system permitted if public sewer is f 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size iFILTER BED ❑ Distance to nearest: Well { Foundation Property Line I SEEPAGE PITS ❑ Depth t Size Number F SUMPS ❑ Distance to nearest:, Well Foundation �'._A-'Property-Line I DISPOSAL PONDS ❑ S 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 laws of California." �i The applicant must call for all required 'nspections. Complete drawing on reverse side. Signed X Title: a Date: FO EPARTMENT USE ONLY `� Application Accepted by owbv. Date ��a�- r Area Pit or Grout Inspection Date Final Inspection by MC Date $ Additional Comments ❑ Stk 466-6781 ❑ 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; Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. INFO + EH 13.241REV.1/651 �. EH 14-28 ---