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Ali APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 s PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED • }�_.�, -r , _(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. ;r Job Address1 Dl; r I `� ... City �C1� 11 a Lot Size PM If Owner's Name Address Phone ! Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack Tracy Type of Casing Sp "" ions j ❑ Public f ❑ ❑ Delta Depth of Grout Seal Type of Grout ❑"Irrigation _.-Approx. Depth ❑ Eastern Surface Seal Installed by Repair one ❑ Type of Pump H.P. State Work Done \ Well Destruction ❑ Well Diamete'r Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONJ< iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Rte. Character of soil to a depth of 3 feet:I Water table depth \ SEPTIC TANK h Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Cj Method of Disposal Distance to nearest: Well Foundation "Property Line LEACHING LINE ' ❑' No. & Length of lines Tata! length/size FILTER BEA ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 lays of California." L The applic ti must call f r II requ' ins p tions. Complete drawing on r verse side.. Q Signed p t X y Title: �! VLY Date: i n F R DEPARTMENT USE Or t" �111�\n` r Application Accepted by Date 'tel— Area . b Pit or Grout Inspection y r Date Final Inspection by Date Additioriel Comments: , ' l� El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca,:823-7104 -.,,..❑Tracy -8355-6385- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED A3 RECEIVED BY DATE PERMIT'NO. '+ EH 19-24iREV.1�H5r �� EH 1428