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APPLICATION FOR PERMITAgJ C � x SAN JOAQUIN LOCAL HEALTH DISTRICT n� 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (200) 466-6781 ' PERMIT EXPIRES 7 YEAR FROM DATE ISSUED e (Complete in Triplicate) 117 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. Job Address City Lot Size PM Owner's Name G Address `7 y �� - .. Phone Contractor Address.6&4' �g>2 .i License No/.,( hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI K SEWER LINES SPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type sing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grou Type of Grout ❑ Irrigation ox. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ ype of Pump H.P. State Work ne Cy Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below-501 oQ 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 depth of 3 feet: Water table depot SEPTIC TANK X 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 length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s 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 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 inspecti s. Complate drawing on reverse sid T Signed r Title: Date FOR DEPARTMENT USE ONLY Application Accepted bAy Date t Area Pit or Grout Inspection Date Final Inspection by r Date Additional Comments; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca B23-A04 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE _(� INFO 'AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. + 3-24 1REY.t/651 EtA 114-M d>.0 d>.0 y L_� I y