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I i APPLICATION FOR PERMIT SAN .fOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA " V �.•k 0- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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. X Job Address �d l City Vl Lot Size _ PM i Owner's Name f1 Address Phone IM-Pr 2 -/ ContractorSeW *ddress �• df Lo r License No-4243S1C� Phone —TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH DISTANCE`TO NEAREST:,SEPTIC TANK SEWER LINES DISPO PROP. LINE OUNDATION` AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WEL BLEM AREA (RUCTION SPECIFICATIONS . El Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type Specifications 1-1 Public n Other ll Delta Depth of Grout Sea -Type of Grout � rox. De th I I Eastern Surface Seal Installed by 1 Irrigation pp P - 1 Repair Work Done Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material Itop 501 [\ Depth I Filler MateriaffBelow 501- # TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIR/ADDITION f I DESTRUCTION 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 1, Character of soil to a depth of 3 feet: Water table depth �} SEPTIC TANK ❑ TypeYMfg ! Capacity No. Compartments rtj` PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line r` LEACHING LINE ❑ No. &sLength of lines Total"length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i:I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line SPOSALPONDS ❑ 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 i 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: '9 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 applicanumst call 14 all required inspo'clicPs. Complete drawing on reverse side. i Signed X Title: �� Date: `2 FOR DEPARTMENT USE ONLY r' Application Accepted by __7_ . — Date I �� Area Pit or Grout Inspecti 2' Date Final Inspection by Date { Additional Comments: � �✓ qI�B ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca" 823-7104 ❑ Tracy --- 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO >V�r CASH 0 //_�J///7 f r.EH 13-24(REI/.1 i n 51 �V f �i�C..f '�"r/ moi/ / EH 14-25