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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 160.1 E. HAZELTON AVE,,.STOCKTON, CA (y,� ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED a {Complete in Triplicate),r P,c :' 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. -r Job Address "` City e Lot Size T PM Owner's Name 1��YTOh � �r.._.. . :Address 8Ca`i 1�+�"`SQe.. _ Phone 0—Q- `? Contractor w Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ I.3 }WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ 1SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE V n FOUNDATION AGRICULTURE WELL OT PITS/SUMPS ) INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ 'Man Dia. of Well Excavation Dia. of Wel! Casing ❑,Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta': I f x Depth'of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface, Seal Installed by Repair Work Done Type of Pump H.P. State Work Done_ Well De ion ❑ Well Diameter Sealing Material (top 501 } Depth Filler Material IBelow 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 + Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK Type/Mfg CapacitLIA No. Compartments , PKG. TREATMENT PLT. ❑ '"r Method of Disposal Distance to nearest: Well Foundation Property Line Y LEACHING LINE ❑ No. & Length of lines _F — "' Total length/size_ FILTER BED ❑ Distance to nearest Wel.--I Foundation Property Line SEEPAGE PITS O Depth Size _ Number SUMPS ❑ Distance to nearest: Well - Foundation 1` ` Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesr state laws, and rules and regulations of the San Joaquin Local Health District.. -f- . e following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies th 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 must c II for I aqui i tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY /''��} Application Accepted by �' \►�C `— Date Area tJ !r Pit or Grout Inspecti Date ! Final Inspection by Date `J Additional Comments: 't" � �� l i Yt n'+oJ�r/ -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i + EH 1324"(REV.i/H51 ,C)U 1�7 EH 14-28 -7