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�t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL+HEALTH DISTRICT ~ p 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRE91 YEAR FROM DATE.ISSUED i a1 ,...,, .. (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 wit h 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. v Job AddressQ 1� , } �M Cit / ynn Lot Size= l�fl['� PM Owner's NamY ( ` Address a Ll Phone Contractor Address _.�� _ C:. License No. Fhane � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 'b DESTRUCTION PUMP INSTALLATION Q SYSTEM REPAIR Q O R ❑ DISTANCE SEPTIC TANK. SEWER LINES DISPOSALPROp. LINE TION AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE TYPE OF WEL OBLEM AREA CONST ECIFICATIONS 0 Industrial ❑ Open Bottom ❑ a la ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Casing Specifications_ EJ Public 1 ❑ Other elta Depth of Gro ❑ Irrigation prox. Depth _ ❑-Eastern—Surface..Seal-Installed by— Type of Grout. Repair�Work - n Type of Pump H.P. State Work Done_ Well tion ❑ Well Diameter Sealing Material {top 50') r E 1 Depth R Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Commercial available within 200 feet.) — Other Number of living units: Number of bedrooms t.. Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK p L� Type/Mfg Capacity f No. Compartments PKG. TREATMENT_PLT, LlG W _.'._w Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines r r Total length/size FILTER BED , ❑ Distance to nearest: Well v Foundation "Property Line i SEEPAGE PITS ❑ Depth Size - Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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.. z_ 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, f shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r ired inspections. Compf_e_te'drawing on reverse side. n Signed X lint ]� Y Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by F Date Area Pit or Grout Inspection Date Final Inspection by Date I Additional Comments: '��7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 K j INFO ,q / / RECEIVED BY DATE ](�7PtE�RMIT'N`O. 4 + EH 1429 IREV.i I a sl - y{�'�'