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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Job Address r /` ACC I&O City a Lot Size l�� PM Owner's Name R. TA k a of., i X 1 _ Address Phone Contractors �L e I"z1K� Address % License Ph6ne TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CI DISI'ANCE'TO NEAREST:,SEPTIC TANK "` -SEWER LINES DISPOSAL FLD. PROP. LIME FOUNDAT N AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF W PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open.Bottom Ma a Dia. of"Well Excavation Dia.of Well Easing Q Domestic/Private ❑Gravel'Paok'y ",. cy �- Type of Casing Specifications (1 Public M.Othert r� ❑ Delta Depth of Grout Seal Type of Grout _ I I ifrigatipn __Appro epth I i Eastern Surface Seal installed by Re{air.Wgrk Done - O Type•-of Pump-_ t H.ly. ' State Work Done Well Destruction ❑ Well Diameter Sealing Mated (top 50'1 Depth `Filler Material,(Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-1 1 ,DESTRUCTION I 1 Mo septic system permitted if public sewer is ' I' available within 200 feet.) Installation will serve: Residence J,_1 Commercial Other A umber of living units: f Number of bedrooms— ,: t Character of sotl to a depth of 3 feet: 1, Water table depth f SEPTIC TANK ❑ Type/Mfg t Capacity e_1Z*P No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i A Distance to nearest: Well L Foundation Property Line 6,6 F r r r � .� LEJ4CHING LINE No. &length of Lines r Total length/size M fr FILTER BED ❑ Distance to nearest: :Well./-49! Foundation _.. , Property Line SEEPAGE PITS i l Depth' Size Numbft ! SUMPSVA I Distance to nearest: Well _/004-1 Foundation/ s-7-- PropertvPLine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be,done in accordance with San Joaquin cbunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. "' t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perOnit is issued, I shall not employ any person in such manne'r as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature O certifies the following: "I certify thrat•in the performance of the work-for which=this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." t The applicant must call for all squired inspections. Complete drawing on reverse side. ned X Si r ` oe" 9i. Title: Date: —_ FOR DEPARTMENT USE ONLY Application Accepted by Data � 4�` Areal I Pit;or Grout Inspection by Date Final Inspection by Date 0 O Additional Comments: [31 Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 lb Tracy 835-6385 Applicant - Return all copies to: Environmental-Health Permit/Services 1601 E!Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT,REMITTED„_ GK r RECEIVED BY DATE PERMtT iVO. INFO ��--•��JJ�� CASH +.EH 13-24 1REV.1 i N 51 .. ^_ L✓�ar., p ::-�,,. 4 EH 14-28