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F APPLICATION FOR PERMIT f r SAN JOAQUIN LOCAL HEALTH DISTRICT ' • 1601 E. HAZELTON 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f i Job Address �� I6� 5 l—, -,__ _-_Cit Lot Size PM Owner's Name d Address /'rTYf & Phone Contracto�/��jQQ,�15/ ai Address License Na Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP 1NSTALLATI ❑ SYSTE EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTU ELL a , OTHER WELL-! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE RE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra pe of Casing Specifications M Public 171 Other 'it Dep of Grout Seal Type of Grout I I Irrigation __Appro! Depth l I Eastern Surface al Installed by _ Repair Work Done ❑ Type of Pump H:P. State Work Done _ Well Destruction ❑ Well Diame r t Sealing Material )top 50'1 +� Depth Filler Material ]Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION i I DESTRUCTION 1No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityF No. Compartments PKG. TREATMENT PLT. ❑ I 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 r: SEEPAGE PITS I 1 Depth 1` Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 X Title: ��, �r/ Date: �' 'Jr"�� FOR DEPARTMENT USE ONLY 2 Application Accepted by Date? t S.=Z��7Area �1-) _ Pit or Grout Inspection by bate Final Inspection by �7 Date Additional Comments: ❑.Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 8351385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT RUE AMOUNT REMITTED CK CASH RECEIVED.0Y� DATE PERMIT' 0. Z t + EH 13-24(HEV.rind EH 14-2e / ✓� d'0