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1z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA N 0,[,� Telephone (209) 466-6781 \%, FF PERMIT EXPI[R-ES 1 YEAR FROM DATE ISSUED (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 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. It— Job Address p cittyy, Lot Size 1042 Y/20 PM Owner's Name + �/✓' '� - Address �/D -3,6 . [ � Phone I Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P LEM AREA STRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tr Type of Casing Specifications F1 Public 1 1 Other Delta th of Grout Seal Type of Grout I I I Irrigation Approx. De I 1 Eastern Surfa Seal Installed by - Repair Work Done ❑ Type of Pu H.P- State Work Done_ Well Destruction ❑ Well Dia eter Sealing Material (top 50') Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I 1 DESTRUCTIO INo septic system permitted if public sewer is 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 s No. Compartments PKG. TREATMENT'PLT. C, r Method of Disposal Distance to nearest:t Well Foundation Property line LEACHING LINE ❑ 1 No. & Length of lines= Total length/size FILTER BED ❑ s Distance to nearest: Well Foundation Property tine 0 SEEPAGE PITS I 1 Depth Size t Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i r 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. f 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,.l shalt 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 laws of California." � The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: F DEPARTMENT USE ONLY Application Accepted by Date rea Pit or Grout!Inspection by Date Final Inspection by ate Additional Comments: � ems, - ❑ 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 REMITTEDOA R RECEIVED BY PATE PERMIT NO. INFO ;-I-) -;k -/�]D +.EH 13-24 IREv.ti/H 5f �J�•.� �. �� r7-r7`�� EH 14.26