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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON AVE., STOCKTON, CA \�. �I� � Telephone (209) 466-6781 PERMIT EXPIRES 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. -7 Gj 0 to •- �5 a-C LS If" Job Address5?/5 W City Rot Sizerh PM G Owner's Name Address D Phone Contractor Address �� f 7� Z►2�License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications F`l Public Ll Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation App x. Depth i I Eastern rface Seal Installed by _ Repair Work Done ❑ Type of Pu H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Maters I Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:'• NEW INSTALLATIONX REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 , available within 200 feet.) Installation will serve: Residence—J/ Commercial_ Other Number of living units: Number of bedrooms _ fi Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4�w �—� Method of Disposal Distance to nearest: Well Foundation Property Line �S LEACHING LINE No. & Length of lines — Total length/size a. FILTER BED ❑ Distance to nearest: Well l� Foundation _A'rO APT Property Line ' P - r SEEPAGE PITS I 1 Depth Size Number V" SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 9r4icensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for al equired inspections. Complete drawing on reverse side. Signed X - Title: �Q� Data: F DEPARTMENT USE ONLY /37 Application Accepted by a Date �� + Area Pit or Grout Inspection by ate Final Inspection by i 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. CK AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.i r n 51 O (� � V SU j EH 14-2a