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- APPLICATION FOR PERMIT �* SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address • f'City r' ) Lot Size Q Q� PM Owner's Name ! Address 3 7 S. W GC Phone Contractor rrl aSL{/ Il Address • Q License No. qN Phone " ., TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL ON ❑ SYSTEM REPAI OTHER El NCE -TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO EM AREA C TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications L1 Public ❑ Other elta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. D ❑ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of ump H.P. 'State Work Done Well Destruction ❑ Well Diameter Sealing Mate ' [top 501 _ Depth ,,...Filler•Material fBelnuir 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is '� h oInstallation will serve: Residence, Commercial, Other available within 200 feet) Number of living units: Number of bedrooms Character of soil to a d pth of 3 feet: I Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments /,� PKG. TREATMENT PLT. y Method of Disposal `�Y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size .FILTER BED ❑ Distance to natrest: Well Foundation Property Line i SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D I herebycerti prepared pp r �. fy,that I have re ared this application and that the work wd.be done in accordance with San Joaquin county ordinances, state laws, and FH es and regulations of the San Joaquin Local Health District. t me owner or licensed agents signature certifiethe.followjng:-''I certify4that in the performance of the work for which phis permit is issued, I shall not ployany person)n such marrneras fSbecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature rtifies the followiwg: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- n laws of Califai7lia."wt ..e applicant must f all required ins do Complete drawing on,reverse side. Signedi Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk "466-6781 ❑ Lodi 369-3621 ❑ Writeca 823-7104 ❑ Tracy 8355-6385 Applicanf,i Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DEATE + EH 13-24(REV.I/R Sl ��77{� �/ EH 14.26 �� C �� QC3 �-l.c] / � p�