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APPLICATION FOR PERMITS r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA No I,t► Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NO prL- s� (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 Address1 L City. Lot Size PM �t Owner's Name Address Phone U 3 Contractor Address _ /2/044Jcense No. Phonef 0 TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWE LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRI ULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE REA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open BottomAlstern Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PackType of Casing Specifications Cl Public ❑ OtherDepth of Grout Seal Type of Grout I I Irrigation _.Approx. DSurface Seal Installed by Repair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diameterg Material (top 50')DepthMaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITIOf�,{I D TRUCTION l (No septic system permitted if public sewer is v table within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedroo Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ethod of D osal Distance to nearest: Wel Foundation Property ins LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: /ell Foundation Props 'ne SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Li e DISPOSAL PONDS El I hereby certify that I have prepared this application and that the ork will be done in accordance 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 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 applicantAnust callf squired ' spections. Complete drawing on reverse side. r R Signed X Title: GC.��/( / Date: u EPARTMENT USE ONLY Application Accepted bye. Y� Date Area �- Pit or Grout Inspection by Date Final Inspection by 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 CK CASH RECEIVED BY DATE PERMITNO. + EH 1 . 3.24(REV.i i n 51 1 0 ^7 EH 14-Ze D `-- �^^