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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address A077 E G 144,4191 City S ✓ Lot Size PM r Owner's Name 1--PS Address 1E Phone Contractor�W,041 b Address 70. 5T License No.J§Z�—Phone 9'6;C3,9 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ T T DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE DNSTRIJCTiON SPECIFICATIONS �J 1-1Industrial ❑ Open Bottom ❑ Mani Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications 71 Public Cl Other-- - Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _-Approx epth I I Eastern Surface Seal Installed by - = Repair Work Done L1 Type of Pu p H.P. State Work Done + Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SFPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms w depth Character of sofl to a depth of 3 feet: Water table de_ P -- SEPTIC TANK ❑ Type/Mfg Capacity g No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS V I Depth Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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 It 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 theworkfor 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X�lifa-��lil/� _ -_Title: Date: � dl FOR DEPARTMENT USE ONLY Application Acceptedby Date —,F Area _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: d ti 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ danteca 823-7104 ❑ Tracy 835-6385 F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 c- FEE AMOUNT DUE AMOUNT REMITTED O SH RECEIVED BY DATE PERMIT-NO. INFO i EH 13241REV.t/N51 ( EH 14-26-, f �..