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�s APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT p ' r 1601 E. HAZEL 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. Job Address City Lot Size PM Owner's Namey_ ,/Q Addresses /?'77 Phone Contractor s er l Address 3f &,?P—/&License N r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOy>&;;�. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Plis4sumps _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR (CATIONS ' ❑ Industrial ❑ Open Bottom �E] an ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac acy Type of Casing Spec cations❑ Public ❑ lta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done ^� Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION rZ'(No septic system permitted if public sewer is available 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 to LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS.. --- ❑ Depth Size Number 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 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 Calif ia." The applicant s call for all required 'nspections. Complete drawing on reverse side. _ r Q Signed Title: _ Date: �l r U / FOR DEPARYMENT USE ONLY Applic ton Accepted by Date �— Area Pit or Grout Inspection by Date Final InspecUOn by �'� Date. "�� Additional Comments: +— a-lh ❑ Stk 466-6781 ❑ Lodi 369-3621 DOMenteca 823-7104 IfTracy 835- A C ' o:/ 160�Hazelton Ave P.O. Bos 20P, Stk., CA 95201 ptir �P_, pp tees t- Return all copies Environm nt I Health EF AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT"N0. EH 13-241REV.t/95) „�.► -- -3 EH 1428