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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT N DpiLl� ; 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 112091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) `� - Application is hereby made to the San Joaquin Local Health District fora 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 �7� PG�.*S.+1.r17! A C/Lc City S_Z�_.c� _ Lot Size PM Owner's Name A$10E/Z/Go G'O,P�pr�SS/ Address Phone Contractor_iFL :�KP Lc/"2> Address 124A�Al, icense No. Z Y7L Phones TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L3 'ON ❑ PUMP INSTALLATION El SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _; ump ppro epth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type H.P. State Work Done Well Destruction LlW II Diameter Sealing Material (top 50`) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION- (No septic system permitted if public sewer is / available within 200 feet.) Y Installation will serve: Residence Commercial_ Other Number of living units: _L..` Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS ❑ Depth Size 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: F DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by l Date Final Inspection by Date 61—Z —7 7 Additional Comments: N rvu7-S G, r t r " ) — . S( -e r t---)"-it— ce;—" ❑ Stk 466-6781 ❑ Lodi 369-bQ1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l---)4—a-,4- (_r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED < CASH RECEIVED BY DATE PERMIVNO. + EHi3-24(REV.1i85) EH 14.26 ��/ f C/