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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT v 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. r o—7 Job Address � _50 /�w o 10 E City X4744Lot Size X e PM Owner's Named Address f l �� Phone Contractor G . A,0190'A) Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `_Qlki€R-E� DISTANCE TO NEA EPTIC TANK SEWER LINES fIJAL FLD. PROP. LINE FOUNDA AGRICULTURE WE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of OPI't vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications M 1 Public fl Other n Delta Depth of Grout Seal a of Grout I I IrrigationApprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done Type of Pump H.P. State Work Done_ Well Destro n ❑ Well Diameter Sealing Material (top 501 Ln Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I DESTRUCTIONIVI (Nolseptic system permitted if public.sewer is F� available within 200 feet.) Installation will serve: Residence_ Commercial e Other V Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L Water table depth V) SEPTIC TANK El 'Type/Mfg Capacity No. Compartments J PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propeity Line LEACHING LINE ❑ No.,& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation PropertysLine_i SEEPAGE PITS I I 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 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,1 shall employ persons subject to.workman's compensa- tion laws of California." The applica nrlvMjst call for all-required inspecti s. Complete drawing on reverse side. i Signed X Title: Date i FOR DEPARTMENT USE ONLY - � I Application Acceptedby Date v Area Pit or Grout Inspectio Date Final.Inspection by Date Additional Comments: P .. ❑ Stk 466-6781 El Lodi 369-3621 ❑� 82 -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. FEE+ EH13-24IREV.1/851 — T2 87-3,2