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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT r'] 1601 E. HAZEL(ON AVE.,. STOCKTON, CA V (/ Telephone (209) 466-6781 I r 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 l +� City �" h Lot Size PM I Owner's-N- i� Address Phone k I-) 6�0 ��' 'E Pont ractdr (A � Address License No.. Phone 44 TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT El DESTRUCTION PUMP'INSTALLATION ❑ ` . ` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO EST: SEPTIC TANK ► SEWER LINES D AL FLD. PROP. LINE NDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Dep f Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Sea lied by i Repair Work Done Type of Pump H.P. State Work Done Well Destruct' ❑ Well Diameter ' Sealing Material (top 50'1 Depth Filler Material (Below 50'1" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONK(No�septic system permitted if public sewer is y available within 200 feet.) nstallation will serve: Residence_ Commercial_ Other A. ,l t Num f living units: Number of bedrooms i Character of ' to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capaci No. Compartments E PKG. TREATMENT PLT. El Method of Disposal Distance nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of��lin Total-length/size FILTER BED 11Distance to er�aTest: i Well Foundation Property Line SEEPAGE PITS 2r-Depth Size Number SUMPS ❑ Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l 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. - r 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 subcontracting 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 applicant must call for all required in ctions. Complete drawing on reverse side. , s Signed I.X Title: Date: i f f , -• -FOR DEPARTMENT USE ONLY o- Application Accepted by Date Area Pit rea __ I Pit or Grout Inspection by Date` Final Inspection by Date Additional Comments: - 7 ❑ Stk 466-6781 , ❑ Lodi 369-ilMll 174Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. + EH 13-24(RE V.1/88J EH 14-26 WA2 (/ I