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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA } Telephone {209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M � � (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 Address4CityZb&_-L-ot Size ��`' j-5,M Owner's Name _..L.re ddress asp-.. 46 ae_ r 0L1V170 _ Phone r Contractor&,,�,,6;,.. I!?" Address �!/i`�i/crCJ gC3!ql-rL 122!--License No Phone 9 fs TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac�eplhastern cy ----- —Type-of Casing - - Specifications f'l Public ❑ Otherelta Depth of Grout Seal Type of Grout I I Irrigation -Ap Surface Seal Installed by Repair Work Done ❑ of Pump H,P. State Work Done_ Well Destructio We�11'0i.mler Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l)( (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK )< TypelMfg Capacity No. 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 11 Depth Size Number SUMPS 0 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." Contractors 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." Th., applicant mu call for ail require inspections. Complete drawing on reverse side. sign Title: 'tJ4a�Z'--t_� Date: FOR DEPARTMENT USE ONLY Application Accepted h Date Area V Pit or Grout inspection Date Final Inspection by Date Additional Comments: LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA f 01 FEE INFO AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED BY:Lb D(ATE / PERMIT'NO. 4.4 + EH 1t 26 IREV.4/H 57 .. ~! C� 1 ff/—.