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i APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, 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. �t Job Address s City SG z2l n�t Size PM }Owner's Name ss / 25 Phone 42 ntractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ W L REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of ell Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of C ing Specifications I (`l Public til Other I Cl Delta Depth of Gro t Seal Type of Grout I I Irrigation —__Approx. Depth I I Eastern Surface Seal In lled by V Repair Work Done ❑ Type of Pump ( H. State Work Done Well Destruction ❑ Well Diameter P ealing Material (top 50'1 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is """7 available within 200 feet.) Installation will serve: Residence_' Commercial_ O her Number of living Number of bedrooms Character of soil to a dept Water table depth SEPTIC TANK ❑ Type fg Capacity No. Compartments PKG. TREAT _ Method of Disposal distance to nearest; Well --�uf�al�on Property Line a LEACR1�i�NE o. $r Leng of Ii s Tota lengt . e FILTER BED Distance to eares. Well Foundation Pro rty Lin L SEEPAGE PITS i I Depth Size Nur iber SIN SUp A d ^,� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS r 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." t The applicant rgtist callor all equired iyspections. Complete drawing on reverse side. Signed X /!s%+[ / Title:� vL�twt_�--- _ Date: __ l L l v FORDEPARTMENT USE ONLY pp Application Accepted by Date "' D Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma 7104 ❑ 5 Applicant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 INFOFEE AMOUNT DUE I AMOUNT REMITTED /]LAK, RECEIVED BY PATE /) PERMIT'No. + EH 13-241REV.1/N 5) 1 (f V 3" 'V 0 !J- ! y A EH 14-20 ! ``