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Iwo 1A ill I APPLICATION FOR PERMIT ®r. SAN JOAQUIN LOCAL HEALTH DISTRICT ry 160' E. HAZE T ON AVE., STOCKTON, CA C `` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applies 1,on is hereby made to the San Joaquin Locai -(!alth District for a permit to construct and;cr install the work herein described. This application is made ir;compliance with San Joaquin County Ordinar: No. 549 for sewage or No. 1862 for well/p,.;:rip and the Rules and Regulations of the San Joaquin Local Ha lith District. Job Adrfrti-ss � � �� =,a; � ,. - - Cityi'1 % Lot Size PM- — Owner's Name ," ° > `� � -- �� L v Address vcj Phone Contra — > F Addre , f �`i+ Lic rise NQ1 !� Phone 0 TYPE (;r 'VELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [ SYSTEM REPAIR ❑ OTHER ❑ DISTAN(-,F TO NEAREST: SEPTIC TANK _ SEWER LINES DISP05:L F ....PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTF,' i,ED USE TYPE OF WELL PR PSLEM AREA CONS ION SPECIFICA?IONS i 1 indusr .;I ❑ Open Bottom C .9,anteca a. of Well Excavation Dia. of Well Casing Domer t c/Private Ll Gravel Pack ❑ cy Type of Casing I P11bh_ Specifications Other ` ! :-!ta Depth of Grout Seal I I Irric au:;r; Type of Grout__, J _-_ A Approx. Depth I I -- PF p astern Surface Seal Installed by Repair V :,a Done I.7 Type of Pump H.P. -- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE Of EPTIC WORK: NEW INSTALLATION l f?EPAIR/ADDITION DESTRUCTION f 'No septic system permitted if public sewer is Installation will serve: Residence_ Commercial _ Other available within 200 feet.) ( n "t Number ;:f living units: Number of bedroor—, Charar.tei of soil to a depth of 3 feet: SEPTIC TANK - —Water table depth [� Type/Mfg PKG. TREATMENT PLT. [ICapacity No. Compartments Method of Disposal Distance to nearest: niell Foundation Property Line LEACHING LINE Ll No. & Length of lines d Total len,th/size fle� j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth '� 57 , Size-_. � !IT Number 0 SUMPS II Distance to nearest: Welli Foundation Property Line C��, DISPOSAL. PONDS ❑ I hereby certify that I have prepared this application anti trial the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health t)strict. Home owner or licensed agent's signature certifies the tollowing: "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 subje.s to workman's compensation laws of California " Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance r+the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m st call for all required i pections. Cc -:.t late draAing on reverse side. Signed X- _ j .74 it Title: Date: oft- ` 1 FOR DEPARTMENT USE ONLY q Application Accepted by ' 1 -,moi 0', w! Dates__:` -7 F� \ Area Pit or Grout Inspection by ate Final Inspection byD z - ate Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Ma-teca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Pr, nit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT =EMITTEDCK A INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.i EH t4-26 70, J ,,, /