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APPLICATION FOR PERMIT 1 � SAN JOAQUINtLOCAL HEALTH DISTRICT I IG 1601 E. HAZELRTON AVE., STOCKTON, CA Telephone (209) 466-6* . PERMIT EXPIRES.1 .YEAR FRQM;DATE.ISSUED { 3, (Complete in Triplicate) !u nc4, . 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. .t I SO . 7f City -�l 10 !tom Lot Size d PM Job Address _ , i - - Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r -PUMP INSTALLATION ❑ :1 SYSTEM REPAIR ❑ ..#r R ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOS�FFLD'_�_.___ s,r FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CON ____r N SPECIFICATIONS G ❑ Industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing F1 ,a ❑ GraveliPackracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Ll Irrigation prox. Depth ❑ Eastern ;III _ Surface Seal Installed by Repair Work Done Type"of Pump H,P. State Work Done Well Destruct' ❑ Well Diameter Sealing Material (top 50') Depth. Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is c.m _ _ „ - .• _ .. ._ i 'w'.-,n'_' • '�Lvailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other :9 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. ❑ EI Method of Disposal l Distance to nearest: Well �I Foundation Property Line w LEACHING LINE It No. & Length of lines �� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line EM SEEPAGE PITS ❑ Depth Size Number .SUMPS ❑ Distance to nearest:" Well- �, Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the w�ork will be done in accordance with San Joaquin county ordinances, state laws, and F 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." A Th I' ant t call for all requi ed inspections. Complete drawing on reverse side. Signed Title: Date: it FOR D`EPARTiNENT USE ONLY Application Accepted by li" Date Pit or Grout Inspection Date Final Inspectio b Date Additional Comments:' �-'w`r ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Mante 823-7104 ❑ Tracy 8354KM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 9/Qr/7— + EH 1 3-24IREV.i/asl dt _ G1 3�5 EH 1428 r