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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL WCALTH DISTRICT c. 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 486-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made io 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 Otdinanco No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� J SG ` __ ^to City f�4G! Lot Size PM / Owner's Name `s FJ�nWnAddress GS[l t to �`I( 5' a Phone 1 { Phone Ci Address lG b}�` -- j Contractor _[�+ t.t- ��i p License i'fo. 7 �o4 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER CJ DISTANCE TO NEAREST: SEPTIC TANK �_- SEWER LINES __ - DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL, -" OTHER WELL _ PITS/SUMPS _ -_- INTENDED USE TYPE OF WELL PROBL AREA eONSTRUCTION SPECIFICATIONS O industrial C1 Open Bottom O Mantec DIa. of Walt Excavation Dia:of Well Casing O Domestic/Private (l g Gravel Pack 0 T y Type of Casing Specifications I ("7 Public Ll Other Delta Depth of Grout Seal Type of Grout___ _ I I Irrigation Approx. De I I Easlorn uriaee Seal Installed by Repair Work Done L7 Typo of Pum H.P. State Work Done Well Destruction Ll Well Diameter Sealing Material (top 501 Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION PT REPAIR/ADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re$idence Commercial— Other_ Number of living units: Number of bedrooms Character of soil to a depthh f 3 feet:�t>�0 b Water table depth _ SEPTIC TANK Type/Mfg �-- CQt�tGl e/�e� capacity_� �_ No. Compartments _ PKG. TREATMENT PLT.❑ r ! Method ofDDispoial W _ Distance to nearest: ell- I a 0 Foundation.__/0 Property line__..0- LEACHING LINE V--N-o. & Length of lines _�__ . Total length/slie FILTER BED ❑ Distance to nearest: Well )0 Foundation _ Property Line J SEEPAGE PITS I 1 Depth _ 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 accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D3lrict. I"I %., Home owner or licensed agent's signature certifies the following:"I coriify 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 componsatidn laws of California."Contractor's hiring or sub-contracting signature certifles 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 compansa. tion laws of California." The applicant must call r ell requir d inspections. Complete drawing on reverse side. Signed X-- — _ --- Date:7 �- FOR DEPARTMENT USE ONLY `Application Accepted by Date_ Area Pit or Grout inspection by Dat" Final inspection by Date ' Additional Comments: ❑ Stk 466.6781 O Lodi 369.3621 ❑ Manteca 823-7104 0 Tracy 835-6W5 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 CK RECEIVED BY PATE PERMIT'NO. , INFO _ CASH U ♦.Err13-24(REV.ifn5) EH 11.26 v