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APPLICATION FOR PERMIT . SAN JOAQUIN LOCALMEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I U PERMIT EXPIRES TYEAR FROM DATE ISSUED a IComplete 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.- Job istrict Job Addressc � -.! G`!�f Ci4-,&A20 Lot Size PM Owner's Name Address'&/- h 12 Phone r+ PContractor Address , License No. s8 Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANC O NEAREST:.SEPTIC.TANK SEWER LINES DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL R WELL_ PITS/SUMPS INTENDED USE TY PROBLEM AREA CON TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Casing Specifications FI Public ❑ Other 171 Delta Depth of Gro at Type of Grout I I Irrigation A X. Depth l I Eastern Surface Seal Installed b _ Repair Work Done ❑ pe of Pump H.P. State Wora Well Destruction Well Diameter Sealing Material (top 50') DepthFiller Material {Below 50'1 i 1 TYPE OF SEPTIC WORK: NEW INSTALLATION f.I REPAIR/ADDITION { I DESTRUCTI (No septic system permitted if public sewer is 1 available within 200 feet.) do Installation will serve: Residence_ Commercial_ Other �I r Number of living units: Number of bedrooms I 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK-, ❑ Type/Mfg Capacity No. Compartments - t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4/r' FILTER BED ❑ Distance to nearest: .. Well Foundation Property Line m � 1 i SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation . Property Line y DISPOSAL PONDS ❑ s 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 r 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 Cali nia." The apptican mu f all requi inspections. Complete drawing on r se side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by -' Date 1 r Area y i Pit or Grout Inspection Date Final Inspection by Data 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 FEEx INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(ACV.I y K 5) -•EH 14-20