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r APPLICATION FOR PERMIT SAN'JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11-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, Job Address 2,nCQ 9 City Lot Size PM Owner's Name Address Phone (0 19,31 Contractor �✓ n ss ! /"__ __License fVo. iv 9 Phone! Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC�TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RIC TURF WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS Cl Industrial ° ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications M Public Fl Other ❑ De a Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l 1 E stern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material 1Below 501 r 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I&r REPAIR/ADDITION l l DESTRUCTION I I iNo septic system permitted if public sewer is "t available within 200 feet.) Installation will serve: ResidenceCommercial Other_ Number of living units: i Number of bedrooms Character of soil to a depth.of 3 feet: On Water table depth SEPTIC TANK O' Type/Mfg opacity U No. Compartments PKG. TREATMENT PLT.,❑ "r - Method of Dispo al �l a R Distance to nearest: Well 10v Foundation Property Line �7 LEACHING LINE L1mNo. & Length of lines Total length/size G FILTER BED ❑ Distance to nearest: Well/r�r� Foundation P n Property Line SEEPAGE PITS 11 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 Dibtrict. 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." Contractors hiring or subcontracting 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 ust call for al quired ins ctions. Complete drawing on reverse side. Jz;;v Signed c Title: Date: °��- _-- j�OR DJ ARTMENT USE ONLY Application Accepted by / Date 9' !/ Area Pit or Grout Inspection by Date- Final Inspection by Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. # INFO ..EH 13.24(REV.I/R 5) Eli 14-211 --------------