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APPLICATION FOR PERMIT �- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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, d I Job Address ` m5)� �pn 4 GLG. City Lot Size PM Owner's Name Be-r, Address Al 75 al rC, & Phone Contractor j@Address 7 �� v t �* License No. 666 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I-] ? DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ ^ OTHER ❑ DISTANCE TO NEARE TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS �1`I INTENDED USE TYPE OF WELL PROS A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ta. II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications + l'l Public ❑ Other C] pelta Depth of Grout Seal Type of Grout ! I I Irrigation -Approx. Depth I i Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. I I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material,(Below 50'.) TYPE OF SEPTIC WORK: NEW INSTALLATION i'l`. REPAIR/ADDITION l I -DESTRUCTION XINo septic system permitted if public sewer is ( ailable within 200 feet.) Installation will serve: Residence_ Commercial— Other j Number of living units: !Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg E Capacity .. No. Compartments PKG. TREATMENT PLT. ❑ i y Method of Disposal Distance to nearest: 7 Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' ` SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line T DISPOSAL PONOS ❑ "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 Di§trict. 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 appfica st'call for all required inspec'ons. Complete drawing on reverse side. Signed Title: Date:. �! FOR DEPARTMENT USE ONLY Application Accepted by Date r'�ea Pit or Grout Inspection by Date Final Inspectizr:�Od/v CIC—a Datl ! -_ Additional Comments: ❑ Stk 466-5781 ❑ 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK si RECEIVED BY DATE PERMIT'NO. 3s�< 3S� o 3 a;EH 13-24 1REV.t/x 51 �' cal 1A_ EH 14-26 S