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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A 1601 E. HAZELT ON AVE., STOCKTON, CA Telephohe-1209) 466-6781 Y 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. . r Job Address V 4 f f+ ��}V� t3 �' City :3T0CJ&01\_ Lot Size PM �f� �j 1 C q6,o Owner's Name W ers sr, Address O �l E I?/ J Phone 1� Contractor '� Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I t\. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT)ONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Will Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing tij �. Specifications 1-1 Public ❑ Other n Delta Depth of Grout Sepl y,Type,of Grout �} I I Irrigation Approx. Depth I I Eastern F Surface Seal Installer y � —.- • , Repair Work Done ❑ Type of Pump H.P. r State Work Don Well Destruction ❑ Well Diameter Sealing Matetial (top.501 Depth Filler Material 18olow 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION €'I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial— Other Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 1 �� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �7 SEEPAGE PITS I I Depth Size Number SUMPS L-i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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." The applicant must all for requi od ins c plot drawing on reverse side. Signed X G Title: Date: {V2 FOR DEPARTMENT USE ONLY Application Accepted by ��JJ date Area r� Pit or Grout inspection by —�� Date Final Inspection b Additional Comments: ��`�y � 1 ' `/(� (' 2T!9 ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Maptica 823-7104 ❑ Tray 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, $tk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24 IREV.,/n 57 ` 7 X- 33 EH 14-28