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APPLICATION FOR PERMIT 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. 1562 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i r Job Address J�5 h/4576 .• y City Ck�/��ot Size �� .1 V PM ELI` c�i�.d Owner's Name � - )Ci0�/y Address :5(15 'sIYtfs-M Phone G f tan, 9 4� - 33 Contractor � ` `a S I Address �� Q , t-t License No. �Sz Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE IC TANK SEWER LINES DISPOS PROP. LINE FOUNDATI AGRICULTURE WELL THER WELT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. o cavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 'y ❑ Public ❑ Othe ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth• ❑ Eastern Surface Seal Installed by Repair Wo ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material(Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (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,f^ni a depth of 3 feet: Water table depth SEPTIC TANK ❑ Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Pr perty'Lrn LEACHING LINE ❑ No. & Length of lines T6faf length/size FILTER BED ❑ Distance to nearest: � Foundation Property Line. SEEPAGE PITS epth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DIS SAL PONDS . ❑ I here .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 ap licant must call for quire inspe ns. Complete drawing on reverse side. Signed Title: —HpY9h4Cn(AjA]2'1k— Date: [5tbr1 . 61,11,14 FOR DEPARTMENT USE ONLY �j�j Application Accepted by Date —AS " r Area Pit or Grout Inspection by Date Fi al Inspection by Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca. .823-7104. ❑#Tacy 635-*5 Af- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITV'NO. + (REV. EH 14-28