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APPLICATION FOR PERMIT i ! SAN JOAQUIN LOCAL HEALTH DISTRICT tszi.%..a �� 1601 E. HAZE T ON AVE., STOCKTON, CA E Telephone (209) 466-6781° {gyp x :PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l' t Job Address �? *,-A7-0�4 City S,042-- Lot Size PM k t Owner's Name Address Phone q� �O�ft/S7s4�crc�L s�cj w � I t. Address_ t. License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT El DESTRUCTION ❑ UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: S C TANK SEWER LINES DISPOSAL FLD. PROP..LINE FOUNDA AGRICULTURE WELL OTHER WELL /SUMPS V INTENDED USE TYPE OF WELL M AREA CONSTRU� CUQW55ECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications. ` i'l Public f_1 Other � to Depth of Grout Sea �'� T YPe of Grout I I Irrigation _—.-Approx. l 1 Eastern —"Surface Seal Installed by It - Repair Work Done ❑ Ty Limp H.P. ..-Slate Work O0.1 ------ Well ne —Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Mater`iat (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION i (No septic system permitted if public sewer is ailable 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: 1 Water table depth SEPTIC TANK ❑ Type/Mfg: Capacity' No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines ! 'E t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size -- Number SUMPS LI Distance to nearest: Well a Foundation Property Line DISPOSAL PONDS ❑ I 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." 3 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,f shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR I ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ate 0AFer—A Ll Additional Comments: / ovf� Jz., It a ❑ Stk 466-6781 ❑ Lodi 369-#21 ❑ Manteca 823-71+34 ❑ Tracy 635-6385 6 s.,�f'l 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 AS RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 IR 1ix51 EH 14-26 .