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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 weli/pump and the Rules and Regulations of the San Joaquin Local Health District. X ' 2 /tri�s PM Job Address �G U Cit /✓ Lot Size__.. a2U-7. ,<Owner's Name 'r3 /'�� i�/SL?SGrr/ Address ✓ gU J ✓� /� ��- Phone �� U �Con(ra�l i /e �N Address �� C f�R�� License No. 35&-79 Pho e'1 1 TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM REP R ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM Aae CTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Mantecaell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyof sing Specifications V f`l Public 171 Other `l Delta of out Seal Type of Grout-__ I I Irrigation _.Approx. Depth I I East,,,,, e Sea Installed byRepair Work Done ❑ Type of Pump HState Work DoneWell Destruction ❑ Weil Diameter S (top 50'1Depth Felow 50'1 \ TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION l I OESTROCTION I4(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence--Z-- Commercial_ Other Number of living units: --L_ Number of bedrooms 2 ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V� Type/Mfg LUa Capacity t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 70Foundation Property Line �3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED t ❑ Distance to nearest: Well Foundation Property Line MSEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 must tali for all re .red inspections. Complete drawing on reverse side. v Signed Xi GL/ � /LG}/,z/i Title: Date: i �) F DEPARTMENT USE ONLY Application Accepted by Date t Area I Pit or Grout Inspection by Date Final Inspection by Date j 3 Additional Comments: th a f < 0if ,L4 S ° t.. Qtr " � ❑ nk 466-6781 ❑ Lodi 369-3621 ❑ Mant EIM 104 ❑ Tracy v 835 fi385 ep 7 c �� - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 01 IFEE NFO OUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY �{ DATE[�'^� PERMIT'NO.. J + EH 13-24 IREV. EH 14-26 f��