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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1 1 E. HAZEL T ON AVE., STOCKTON, CA �� Telephone (209) 466-6781 .60PERMIT EXPIRES T YEAR FROM DATE ISSUED ,: I (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, Joh Address V toe 1,q\a 'JQ City S fJC �''� Lot��Size00 PM LQ Olt � c� PQ� - Address Phone Owner's Name tt C_ Contractor � 1 Gla lf+` '�- Address License No. Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �NOc�*. s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES laf�� -- DISPOSAL FLD. PROP. L \ 1 FOUNDATION AGRICULTURE WELL OTHER WELCH PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing S ecifications [I Domestic/Private El Gravel Pack El Tracy Type of Casing P M Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout fb ; p A rox. Depth I I Eastern Surface Seal Installed by o- I I Irrigation -- PP P. H.P. State Work Done Repair Work Done ❑ Type of Pump ' a Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTI WORK: NEW INSTALLATION [1 REPAIR/ADDITION l I DESTRUCTION [ I (No septic systthinem feetit ed if public sewer is i Installation will serve: Residence_ Commercial Other_ _ R _ ._ - _ - - Number of living units: Number of bedrooms E .. Character of soil to a depth of at.. Water table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal pistance to nearest: Well Foundation Property Line v i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well dation Property Line i �i SEEPAGE PITS I 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 Di?;trict. 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 f certifies the#oHowing: "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 for ail required inspections. Complete drawing reverse �ioe F% j "- SUV O ( Signed X �' — Title: Lk Date: -kbr- �� Q� FOR DEPARTMENT USE ONLY ll6 ' Application Accepted byav?d C�1lS Date 6 Area / # Co Pit or Grout Inspection by Date Final Inspection by date"' Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 }- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, 51k., CA 95291 t FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. INFO ♦.EH 13-24(REV.I i H 5) con EH 14-28