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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. Jab Address CitLot Size !` PM i _ y E Owner's Name ddress - Phone %.2 3 Contracto A h24A, �- dress _ License No. J�! Phone J �G -_ - - TYPE OF WELL/PUMP: NEW WffLL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO410 r.r SYSTEM REPAIR ❑ OTHER ❑ p DISTANCE TO NEAREST: SEPTIC TAN - WER LINES, DISPOSAL FLD. PROP. LINE I FOUNDATION t" GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OB'L M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom _, .❑_ teca -„. ,.,Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr c `Type of Casing I Specifications ' ❑ Public ❑ Other ❑ D Ito Depth of Grout Seal t Type of Grout ❑ Irrigation �4pprox. Depth ❑ astern• 'Surface Seal Installed by-k - P Work Done ❑ Type of Pump H.P. State Work.Dane Well Destruction ❑ Well Diameter'- • . _ j .. Sealing Me ial (top 501 I 4 Depth y Filler Material (Below 50') > TYPE OF SEPTIC WORK: NEW INSTAL N 11REPAIRIADDITION ElOESTRU ION (No septic system permitted if public sewer is � 1 � tk � � a I le hin 2 feet./ Installation will serve: Residence Commercial Other t �I�VZ Number of living unit s: Number of bedroom fr,v� Character of soil to a depth of,3 feet: v F Water table ptH SEPTIC TANK ❑ Type/Mfg Cap ity�2-[G c� No. Compartments + f" PKG. TREATMENT PLT. ❑ 1 *%:Method of Disposal 4 Distance to nearest: Well `,�F' Foundation__ Property'Line _ „- P LEACHING LINE O No. & Length of lines f �% ` ' Total length/size ` 4 FILTER BED ❑ Distance to nearest: lYVell r�1Foundation Property Line f SEEPAGE PITS ❑ DepthSize i- a Number 1 SUMPS 1 ❑ Distance to nearest: Well�=� `ounda�n"�� Property U. ISP AL i DAL PONDS ❑ I hereby certify that I have prepared this application and that the work,ivill be done in accordance with San Joaquin county ordinances,-state laws, and ruleva"nd-regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: i 9 9 g: "I certify that in the performance of the work for which this permit is issued, t 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 thellwork'fcr which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." [ `-Ni `s ' I . 3_ 1 ' I The applica must call for 1 required i spections. Complete drawing on reverse side.- Signed X C ?Title: Date: 7 77 i y FSR DEPARTMENT WWONLY Application Accepted by Date �� ~o Area V k,r Pit or Grout Inspection by Date S�Z Final Inspection b — ` R Date IA Additional Comments: . / ❑ Stk 466-6781 ❑ Lodi 3643621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE_ PERMiT 11E0.1 ,.1NF0_ _ _ CASH + EH 13-24 SREV.1/a 5) '4 771S 7-,?o T EH 1428 i