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APPLICATION FOR PERMIT �.. � SAN JOAQUIN LOCAL HEALTH DISTRICT tet' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (2091 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address J�"��049.,L) CityLot Size X50 PM J /�, / 1 Owner's Name A q ��7�_ l= Address – �� h +��^' Phone 6" Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ lIy PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ DISTA��T�REST: TICTANK SEWER LINES DISPOSAL F PROP. LINENDATION AGRICULTURE WELL OT ELL PITS/SUMPS v INTENDED USE TYPE 0 L PROBLEMAREA CO N SPECIFICATIONS ❑ Industrial ❑ Open Bottom an Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa Tracy Type of Casing Specifications F1 Public t er Cl Delta Dep rout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal insta Repair Work Done ❑ Type of Pump H.P. State Work Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 RFPAIR/ADDITION I I DESTRUCTIO o septic system permitted if public sewer is vailable within 200 feet.l 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 LEACHING LINE ❑ No. & Length of lines 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 PONDS ❑ 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 t call for all required i ctions. omplete drawing on reverse side. / Signed X Title: 04.&J–Ae—)CN_ Date: FOR R DEPARTMENT USE ONLY Application Accepted by ` Date ��t` jkl&,�_' _ Area Pit or Grout Inspection Late Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +.EH 1 -24 1REV.t i H 5} EH 1 4-28 f O