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r r j APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON ON AVE., STOCKTON, CA � Telephone (209) 466-6781 .� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heaeby 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 274 City S T-0C.&01iAJ_ Lot Size PM-10 - Owner's Name T 1fO Address 2 7� $ T 3' 9S 4 NPhone �7 i Contractor E Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ "SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOS PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA C UCTIDN SPECIFICATIONS ❑ Industrial 4 ❑ Open Bottom --s ❑ teca- -Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ; ❑ y Type of Casing Specifications I`I Public 17 Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation �_Appro epth I ] Eastern ace Seal Installed by - Repair Work Done ❑ Type of ump H.P.. I State Work Done _ Well Destruction Q" .Nell Diameter " Seating Material (top '1 Depth Filler Material (Below 501 TYPE OF SEPTIC,WORK: NEW INSTALLATION l l REPAIR)ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is n } y available within 200 feet.) t ' 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 Distance to nearest: Well Foundation Property Line 1 � f LEACHING LINE , ❑ No. & Length of lines j ! Total length/size . FILTER BED ❑ Distance to nearest: Well foundation Property Line rt SEEPAGE PITS P I 1 Depth Size Number SUMPS 0' 'Distanct 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 r rules and regulations of the San Joaquin Local Health Di1trict. 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."Contractors hiring of 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 for all requirA inspections. Complete drawing on reverse side, Signed X Title: Cod k-./ Data: '~T i FOR DEPARTMENT USE ONLY Application Accepted byDate Area Pit or Grout Inspec' n Date Final Inspection by'v /"` "- " Date Additional Comments: �� w+l ❑ 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.Q. Box 2009, Stk., CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �. +.EH13-24(REV.1?K5) �� `-'� �5' EH 14-25