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f /1 APPLICATION FOR PERMIT Zf S SAN JOAQUIN LOCAL-HEALTH DISTRICT 1 1601 E. HAZEL 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 / City 4 Lot Size pM �( Owner's Name dla'I -�_ Address +'!p' �, ------ - : Phone Contractor �� . � _Address --�-- � �__�_ _ ..License No� � Phone TYPE ELL/PUMP: NEW WELL E WELL REPLACEIUIENT„❑- DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER f❑ 3 DISTANCE TO NEARE PTIC TANK SEWER LINES ^ DISPOSAL FLD. __PROP. LINE s I PUMP N �AGRICULTUNL �r_OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM CONSTRUCTfON SPECIFICATIONS i ❑ Industrial ❑ Open Bottom n Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy a of Casing Specifications ❑ Public ❑ Othe ❑ Delta Depth o ' t Seal Type of Grout j ❑ Irrigation �Approx. Depth O Eastern Surface Seal Insta ed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system.permitted if public sewer is Eailabl�within 200 feet.) Installation will serve: Residence_ Commercial_ Other Q,� Numb living units: Number of bedrooms Character_of- o a depth-of 3 feet: Water table depth i SEPTIC TANKType/Mfg ` C ity No. Compartments PKG. TREATMENT PLT. ID Method of Disposal Distance to n V Well ^Foundation - Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER.BED t ❑ Distance to near Well Foundation Property Line e SEEPAGE PITS { ❑ Depth Size ""` - Number SUMPS ❑ Distance to nearest: `_ Well "" Foundation Property tine DISPOSAL PONDS r ❑ = t, I hereby certify that I have prepared this application and that the work will be done in accordanc_e_w_ ith.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 fol/wtify owing: "I certhat 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'i 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 applicant ust call for all required inspectio . Complete drawing on reverse side. R Signed Title:" Date: Cf—co- I i FOR DEPARTMENT USE ONLY ! . . Applic on Accepted�by %A, Date r Area_ _y Pit or Grout Ins ection .D�ate ` Final Inspection by J Date -` Additional Comments r 4 ❑ Stk 466-6781 r ❑ Lodi 369-3621 ❑ Mante F f 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 r FEE r AMOUNT DUE AMOUNT REMITTED —RECEIVED BY DATE PERMIT NO. INFO s CASH v + EH 13-24(RSV.1/8 5) 007—S,7 / EH 14-28 •+�. 1Q(vlt�! o '