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w .` 1 } 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. Job Address 1 �[�23 S' Aoa� City'-jIA' P Lot Size IQCr"- PM t KL Owner's Namelf 1 pA ddress ' a3 44J-0 f\3 Phone Contractor �- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZZ DISPOSAL FLD. PROP.,LINE FOUNDATION RICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation �" Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing Specifications (l Public F1 Other n Delta Depth o rout Seal Type of Grout _ I I Irrigation —,Approx. Depth I I East Surface Seal •taste lled by Repair Work Done ❑ Type of Pump H.P. State Work Done_ vU Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other ^ Number of living units: Numberofbedrooms i 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 LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to:nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number f 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant m/stt call for all required i specti . Complete drawing on reverse side. q Signed Title: V �- Date: ` Z FOR DEPARTMENT USE ONLY (� / Application Accepted by \G Date Ct 'Q a_ n Area Y - Pit or Grout Inspection by Date Final Inspection by: �fr�"/ fl ✓� Date Additional Comments �x -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO I a EH 13-24(REV.t i x 5) PL5.rs� c _ --6 7 EH 14-28 _J"s— L,,�