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r f ..sem•^. ..,,„, yes �, .� .APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 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. iF i Y Job Address ED City ^ Lot Size PM i Owner's Name r Address r y Phon " Contractor Nl Address U2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" SAL FLA." PROP.'LINE FOUNDATION AGRICULTURE WEL OTHER WELt PITS/SUMPS INTENDED USE TYPE OF:WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS i' w ❑ Industrial ❑ Open Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing �❑ Domestic/P.rivate ❑ Gravel Pack Tracy Type of Casing Specifications M Public M Oth 11 ❑ Delta Depth of Grout Seal Type of Grout `1 I I Irritjation �; Approx. Depth. I I Eastern Surface Seal Installed by - Repair Work �e ..❑ Typefof Pump H.P, State Work Done t" Well structiori ❑, Well Diameter Sealing Material (top 50'i Depths Filler Material (Below 50'1 f ry I - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is., available within 200 feet.) < Installation will serve: 'Residence'_ Commercial Other Number of living units: y Number of-bedrooms _ Character of soil to a depth of.3 feet: ater table depth I octrl SEPTIC TANK .`�< ,Type/Mfg Capacity'" No. Compartments t `PKG. TREATMENT PLT. ❑ w t Method of Disposal r Distance to nearest: Weil Foundation 'Property. Line kf Total length/size �" _ 4 7� LEACHING LINE Na. & Length of lies�� : , FILTER BED ❑ Distance to nearest: Well /Ol Foundation Property Line SEE GE Depth !"�Size Number 1 pfQ Distance to nearest: .,.Well�_ Foundation Property Line i - 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 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 rc must call for wired inspections. Complete drawi6g-on reverse-side:-- --r - Sig Title: * Date. 1 i FOR DEPARTMENT USE ONLY Application Accepted_ by ` - a Date Area ©`�✓ / I Pit or Grout Inspection by bate I Final Inspection by �' Date t Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services.1601-E:-Hazelton-Ave,—, P-0. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO /' CASH. . ; E�H 13-24 ER--44-28(REV.1/951 '� 7U fes-" a t0 olr' Q J'��