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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTFICT 1601 E. HAZELiON.AVE., STOCKTON, CA �A ' Telephone (209) 466-6781 PERMIT EXPIRES .1 YEAR FROM DATE ISSUED '(Complete iri Triplicate} j'",,, 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. 'J . < sr 2 ,yi .D " 7 .' .. WItI .:e Er �y CU Job Address ;1 "' �-,V �� M1 City '�'�Lot Size PM " Owner's Name IBJ J .L G.�- �� 'i�� Address 123e 5, Sl ye �� Phone -7- [ �� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIRj❑ THEIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �SPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS (� INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS �f ❑ Industrial ❑ Open Bottom' anteca Dia. of Well Excavation - Dia. of Well Casing O Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing r Specifications ❑ Public ❑ r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �DType —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Wor ne of Pump H.P. State Work Done struction ❑ Well Diameter Sealing Material (top'50') Depth Filler Material (Below 501 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 j Character of soil to a depth of 3 feet: V ' Water table depth SEPTIC TANK >' Type/Mfg 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 . 0 SEEPAGE PITS ❑ Depth Size Number ) SUMPS ❑ 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 F 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." Thea licant ust f r all r quired inspectio s. Complete drawing on reverse side. fed Title: Date: ( � p FOR DEPARTMENT USE ONLY ) i Application Accepted by Date 0`41Are QPit or Grout Inspection Date Final Inspection b Dated Y _ k Additional Comments: r3 Stk 466-6761 ❑ Lodi 369-3621 ❑"Manta 823-7104^ ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952FEE 0 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. ' ASK + EH13-24 1AEV.t/a 51 -(94D �'.� y\ �. �� `�15 d7 EH 14-28 )