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APPLICATION .FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1601 E. HAZEL T ON AVE., STOCKTON, CA yr Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 descri9E`d. T ' app' l!Za 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 16-808 City ZA79AuE Lot Size 76— l�0 PM Ir I Owner's Name !) �� Rs Address T/ �?1 GJ#T l��l' Phone Contractor C`GF Address 43 HHS License No. Phone TYPE OF WELL/PUMP:f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ D DISTANCE TO 5T: SEPTIC TANK SEWER LINES DISP LD. PROP. LINE ATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE PROBLEM A ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pa D Tracy Casing Specifications M Public er !l Delta Depth of Grou Type of Grout _ I Irrigation �-Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Imp 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RI-PAIR/ADDITION l I DESTRUCTION ( INo septic system permitted if public sewer is �. 'awailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mfg . Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . f LEACHING LINE ❑ No. R Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line >r SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL FONDS ❑ 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 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 t become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify jinjh performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Eifornia."The applicant ust" f r respections. Complete drawing on reverse side. r _ �[ Signed X t Title: y 1� � Date: _�. ag FOR DEPARTMENT USE ONLY Application Accepted b /t�'r Date��0 Area 3 e D Pit or Grout Inspale Final Inspectio by�� / / Data Additional Comments: ✓ ❑ Stk. 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ♦ EH 1 -24!REV.1/0 51 `_ EH 144-2a O