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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT *Y 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE-LSSUED (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. 3 Job Address 2 City &Lot SizJe/ W.0— QPM Owner's Name `rte+—t- Address �� 7� Phone Contractork��ddressfcq&+w7 License No.-:3j;2 � ZZ� Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLD. PROP. LINE FOUNDATION AGRICULTU.j3 ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications * Public C1 Other Cl Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation _..Approxi epth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type o ump H.P. State Work Done Well Destruction ❑ Diameter Sealing Material (top 50') T Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION I I Rl'f'AIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public:. i war is ] available within 200 feet.) _T c� - Installation will serve: Residence X Commercial_ Other Number of living units: Number of bedrooms �• "��ii Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity__ No. Compartments " } PKG. TREATMENT PLT. ❑ -Method of Disposal r Distance to nearest: Well NCr Foundation 10 Property Line 100 + LEACHING LINE Ut- No. & Length of lines - Q f 'i Tota! length/size FILTER BED 0 Distance to nearest: Well Foundation�X / Property Line f co SEEPAGE PITS I ) Depth Size tiifiber SUMPS D ' Distance to nearest: Well Foundation Property Line t 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, grid 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 ' certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compelsa<' tion laws of California." , The applicant must call for all required inspections. Complete drawing on reverse side. *, Signed X Title: Date: —30 9 FOR DEPARTMENT USE ONLY /� 7 Application Accepted bylal,0�� ,::;e Date Area 1 Pit or Grout Inspection by Date Z V LZ f Final Inspection by ata r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ID Tracy 835-6385 A/V Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r. +.EH 13-24 IREV.i i x s) EH 14-26 •LL.-' -