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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � Pa 1601 E. HAZEL T ON AVE.,wSTOCKTON, 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. y g . 4 "�J j. L Job Address City � � , Lot.Size �� PM t ! Owner's Name ,tai , 4 xzef! . Address r'3 S _..Ire-rZ f Izv�a-� Phone Contractor Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK LINES' �` DISPOSAL FLD. PROP. LINE - FOUNDATION` 'AGRICULTURE OT I �1! t INTENDED USE TYPE OF WELL PROBLEM ARE RUCTION SPE IONS ❑ Industrial ❑ Open Bottom a eca Dia. of Well Excavation -.a Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Sped s + ❑ Public ❑ r ❑ Delta Depth.of,Grout.Seal M1 Type,of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by � I -t' Repair Wo one El Type of Pump H.P. Stat k Done Well Destr ction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material,(Below 501.- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth' SEPTIC TANK Type/Mfg _t Capacity W No. Compartments PKG, TREATMENT PLT. O T 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 ' t , h SEEPAGE PITS �'` ❑ Depth Size Number SUMPS r ❑ Distance to nearest: Well Foundation Property LinerT'""" DISPOSAL PONDS ❑ Y' 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. b 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,'Contractoi'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.` t The applicant must cap for all �rr q`uiireed inspections. Complete drawing on reverse side. -�JI.LSC C�1 Q„n.�� U Signal X� — Title: —bate FOR FOR DEPARTMENT USE ONLY Application Accepted by Date 1— Area + Pit or Grout Inspectio bate Final Inspection by Da7" tes Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104- ❑ Tracy 835-6385 i 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' C&* RECEIVED BY DATE PERMIT NO. INFO MSH Gid '4 + EH 13-24(REV.F.i H 5) L.J S EH 14-2B