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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT AT 1601 E. HAZE T ON AVE., STOCKTON, CA Na vi �"�`R 1 Telephone (209) 466-6781 G 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. ('Job Address 3N, ' �G/I/Sale e- City 5/0G 4 Lot Size PM � \ r t n /11 G /J`Dwner's Name �� I >iJl le Address �` -/ J �P4 "yl1 " ` Phone <Qontractor Address �✓� "" �Iff, License No. Phare TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWNRINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIRE WELL Z OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRU ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man ;De a. ell Excavation Dia. of Well Casing �r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe ing !� Specifications 1'1 Public n Other F1 Delta of Gro eal Type of GroutI I Irrigation —_Approx. Depth i I Eastern rface Seal Instal byRepair Work Done ❑ Type of Pump H.P. { State Work Done Well Destruction ❑ Well Diameter Sealing Material [top.50') 1.. p Depth ; Filler Material (Below 501.- U— TYPE 0'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i if REPAIRIADDITION 1-1 DESTRUCTION No septic system permitted if public sewer is available within 200 feet.► installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 j��--"" Method of Disposal i i ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ` s Total length/size FILTER BED ❑ Distance to nearest: Well Foundat(ori Property Line i i 4 � SEEPAGE PITS I i Depth Size t I _ 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 accordaae.with San Joaquin county ordinances, state laws, and 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 perfiirmancee-ihe work for which this permit is issued, 1 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 f 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." Y The applicant ust_call for all required i pact ns. Complete drawing on �ersse side. 7 17 -5 igned X Title: Ml`�iT/>'Y`-� Date: �U CC FO RTMENT USE ONLY �� 7 Application Accepted by Gw � _tiQ�bpb_ _ Date- S j J __ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT((REMITTED CASH CK RECEIVED BY DATE PERMIT/''N/O. +.EH 43-24 1REV.i i N 5) CJ ! s `3 �jo EH 14-26 [��