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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ( &.�'�, 1601 E. HAZE.T ON AVE., STOCKTON, CA �j 36 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / C Job Address gig City Lot Size PM 1 Owner's Name to V Address Po 6-oy, 121 Y'ID�a Phone Contractor Address License No, Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR ES TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE W! LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CON ❑ Industrial ❑ Open Bottom eco Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P 0 Tracy Type Ing Specifications f I Public ❑ Ot F1 Delta Depth of Grout Se Type of Grout --- I i Irrigation ,._Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. L State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION t1 DESTRUCTION IX^o septic system permitted if public sewer is vailable 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total IengthLsize FILTER BED 0 Distance to nearest: Well Foundation Property Line � e SEEPAGE PITS i I Depth Size Number SUMPS Ll 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 accprdance 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: Date: FOR DEPARTMENT USE ONLY t �j Application Accepted by Date!Z ✓ � Area Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. ♦.EH 124(REV. /n 51 EH 1a-4-29