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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4666781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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.' Jab Address L � �OS�O�� 75 �— City / - Lot Size PM ✓"C Lir 2 Address s ` 0 d Y Phone n,77ci ! Owner's Name / t , / f 1 Contractor ( `'fir }' L�"T Address ` `�C License no. 1 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL // PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION-0 ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavatio Dia. of Well Casi ❑ Domestic/Privaterayel Pack f7 Tracy Type of Casin Specifications /�UG 1647 ❑ Public s y El Other ❑ Delta Depth of Grout Seal Type of Grout Irri ation ' !r4 � pprox. Depth ❑ Eastern Surface Seal Installed by 9 � Repair Work Done 1❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTiON ❑ (No septic system permiIse-er 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 Disposa r Distance to nearest: Well FoundationProperty Line LEACHING LINE 0'.No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS' ❑ Depth Size t Number SUMPS Q Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A Lhereby 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 the work for which this permit is issued,I shall employ persons subject to workman's compensa- certifiesthe,following:"I certify that in the performance of tion laws of California." ri Thesapplicent t II for a requi d ' spections. Complete drawing on r arse side. /7 Signed Title:�. Date: OR DEPARTMENT USE ONLY l,'� / Application Accepted by � Date T 7 Area �+i Date 6 r `�rFinal Inspection by r'� � Date Pit or Grout Inspection by- / Additional Comments: ❑ Stk 466-6781 ❑ Lodi /369-*1 ❑ Manteca 823-7104 ,E] Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601,E.:•Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CASH', RECEIVED 8Y DATE PERMIT N0. INFO �J A _ -/n + EH 13-241REV.1/65) 7 - EH 14-28 ! r