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C} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1 n j Job Address to 0OJ"7 �.I' 2 / City Lot Size`/7� ��J PM Owner's Name�LA— r .CG'_~ _ __- Address ILA- Phone 1 , Contracto _ d . Address 7& 7 "`^' License No. Z-9 Z-2-4 Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. PROP. LINE FOUNDATION AGRICULTURE'WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU N SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ❑ Tracy ype of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation T__Approx. Depth I I stern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diame Sealing Material {tap 50') Dept Filler Material (Below 50') _ TYPE OF SEPTIC WORK EW INSTALLATION J4 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic.system permitted if public sewer is 1 I's available within 200 feet.i d Installation will serve: Residence_k Commercial_ Other O Number of living units:--IL Number of bedrooms__-�_,..5/� Character of soil to a depth of 3 feet: _J&f1 At4_ Water table-depth SEPTIC TANK fH Type/Mfg G Capacity_ No. Compartments t 1 PKG. TREATMENT PLT. ❑ =ti+ "'I'll Method of.Disposal S Distance to nearest; Well �Krb f Foundation 1.D � Property-Line'- , LEACHIN&LINE No. & Length of lines Ca Total length/size L FILTER BED;', ❑ Distance to nearest: Well d Foundation 1 Property Line S O ,r _. i SEEPAGE PITS 1 1 Depth Size Number l SUMPS ❑ 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 i 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 cal! r all required in ti ns. Complete drawing-on reverse side. -Signed X Title: Date: -� FOR DEPAR MENT USE ONLY , Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Maniacs a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT'NO. INFO f +.EH13-21(REV.tir<s) EH 14-26 -(� 1