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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.CHAZELTON AVE., STOCKTON, CA Telephone QbW 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1F (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 E 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 E Local Health District. Job Address � � � PPPPP ST City Lot Size Z_e',k! fir• PM a ~ t Owner's Name "-Address_-'-Sv1Gr-rE Phone �I Contractor 5-f- O G dress 60.0 IV, t5-/t_1-/.9ir1 4_r/ye License No. ?i[�Y7G Phone 1,4-377 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL LIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPED S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pacfk Ll Type of Casing Specifications ❑ Public ❑ Other { Delta Depth of Grout Seal Type of Grout Q ❑ Irrigation ox. Depth ❑ Eastern Surface Seallnstalled by Repair Work Done ype of Pump H.P. State Work Done j Well Destr ❑ Well Diameter Sealing Material {top 50') y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION VlNo septic system permitted if public sewer is i C available within 200 feet.) Installation will sere: Residence! Commercial Other L Number of living units: } Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK „. �❑ Type/Nfg Capact ty -Water table depth Compartment sPKG. TREATMENT PLT.0 4Method of Disposal '*�• M.,� # _ Distance to nearest: Well Foundation, Property Line LEACHING LINE ❑ No & Length of lines Total length/size FILTER BED 10 Distance tott nearest �. Well Foundation Property Line SEEPAGE PITS ❑ Depths t 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 rules and regulations of the San Joaquin Local Health District. laws, and 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-subiect-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." pt The applicant must call for all required inspections. Com to drawing on reverse side. Signed ' Title: Date: ^� I FOR DEPARTMENT USE ONLY Application Accepted by �+�^-�- Date 4/-/-/ Area Q Pit or Grout Inspection y - Date: Final Inspection by � Y Date l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621.,. ❑ M eca 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 I FEE AMOUNT DUEAMOUNT REMITTED C RECEIVED BY' DATE PERMIT'NO. INFO SH + EH 13-24{REV. /9 sl EH 14-28