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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Nam Telephone (209) 466-6781 PERMIT EXPIRES 1•YEAR FROM DATE ISSUED (Complete in Triplicate) �'Cs� •� 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 1/ ® t A L C City fad r 0 Lot Size PM �u B�i�► �F TX!� sl h i►Q77� -- ?O Owner's Name - f7 _ .� Address @ S. 14 lAt kl it ^ S'-/r--JPhone i Contractor Address License No. �SS Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL LAT ON ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL '`� OTHER WELL_ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROS M .REA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Bottom antec Dia. of Well Excavations Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public n Other F1 Delta Depth of Grout Seal Type of Grout I f Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ 1 i Repair Work Done ❑ Type of Pump H.P. \I . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTIONINo septic system permitted if public sewer is i 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 depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ j- - 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, a 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 mu all for all re ire pectionComplete drawing on rev fse side. -7 Signed X Title: Date: FOftPERARTIVIENT USE ONLY Application Accepted by D to ^�- V� Area t �D�7'1<- 4iw i . r.- Akre - Pit or Grout Inspec' y Date Final Inspection by 'F 4-4 -Z (_ �st�Ct( /`fW?• Z7 tt Additional Commen 7 r a ❑ Stk 466-6781 L i 369-3621 ❑ Man eca 823-7104 ❑ Tracy 835-5385 d�d x of X f rr f "r Le Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2 qStk, CA 95201'f g,A ".TT pp � ..� ire S•ev�+.-�. s IFEE NFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO.�� + EH 13-24(REV.iiK +�� s1 EH 14-20 '�