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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA NOCK Telephone {209) 466-6781 ��4 PERMIT EXPIRES TYEAR FROM DATE ISSUED 2� .(Com lete in Triplicate? p Application is hereby made to the San Joaquin Local Health District fot 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 Address �2_ 3 S j? 6. 4 46C 4,-© --- City A Lot Size 4,A.4,04T� PM Owner's Name Address Phone Contractor SCO Q_C- &/0771? Address AD.C-I-a4f27^-... License No._4 -7-74 Phone T44^ 397 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 FOUNDATION AGRICULTUR LL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-App Depth I Eastern Surface Seal installed by _ Repair Work Done ❑ Type Pump H.P. State Work Done_ i1 Well Destruction ❑ Well Diameter Sealing Material (top 50') yr Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION l I DESTRUCTION'I 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 ` V� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (fin PKG. TREATMENT PLT. ❑ Method of Disposal �R 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 SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 call for all required inspections. Complete drawing on reverse side. Signed �- �/� Title: Date: OR ARTMENT USE ONLY C� ^ y� Application Accepted by Date y�4'�-v� Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 e Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERM17`NO. + EH 13-24IRE:V-1iH5) �� 61`9ovdk �f �'/ EH 14-28 - CJ i