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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. �j ( l�,� Job Address 7 6 e GO D,- ( /'� t' City 5t, f-4 la2)Lot Size 7SX l�S PM Owner's Name Address l 6 l" one w 20 Contractor -5-46 LAddress License No. Rhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU TION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public 11 Other [__1 Delta De of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction E] Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic s-ylmm.permitted if public sewer is 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 �7 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of dines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 must call or all required inspecti Gomple drawing on reverse si �( . 41 Date: � Signed X Title: FOR DEPART T USE ONLY Application Accepted by Date Pit or Grout Inspection by ` Data Final Inspection by Dated ��[) Additional Comments: * �� 7 ❑ Stk 466-6781 Lodi 369-3621 ❑ Man eco 823-7104 El Tracy 835 6385 /Q, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �Y FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO A + EH 13-24 1REV.i r H 57 EH 14-2e I i