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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED r (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 Districto+r ! 4 I Job Address _ 1't �' City Lot Size PM Owner's NameL�.�p� I rT� Address I T r 1 Fr �d e U f t _ Phone414 " Q " Contractor IR2 f^r:S S O'J Address [ g0 F 15 W License No.cV:F 1 I.-Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ � � PUMP INSTALLATION ❑ SYSTEM REPAIR 13 OTHER ❑ DISTANCE TO NEAfI SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFIC TIDNS,'� ❑ Industrial El Bottom ❑ Manteca xcavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack . 1:1Tra Type o Specifications 1-1 Public Cl Other Delta Depth of Grout Type of Grout I I Irrigation --Approx. pth I I Eastern Surface Seal Installed by Repair Work Done E Type of Pump H.P. Y State Work Done _ Well Destruction ❑ Well Diameter ? Sealing Material Itop'50') Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 REPAIR/ADDITION I I DESTRUCTION o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial-. Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth 1 s: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line' i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line }f , t SEEPAGE PITS I I Depth 'Size L Number i SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ T f 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." I The applicant�must call for all required inspections. Complete drawing on reverse side. I Signed X Title: eel Date: c07/ FOR DEPARTMENT USE ONLY C I Application Accepted by Date Area Pit or Grout Inspection S rr Date Final Inspection by_ Date Additional Comments: _ C �C G�� ❑ Stk 466,6781 ❑ Lodi 369-3621 ❑ Vanteca 823-7104 ❑ Tracy 835-6385 Applicant = Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201_ INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.". +.1SH13-24 1iiEV.v/x 51 EH 14-29 f `[ —