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APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f 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. Jab AddressCity Lot Size L ^ PM Owner's Name�/�2GU' l�Y'--�' Address S , Phone F3/— �/Z _Contractor ddress License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ .DESTRUCTION ❑ PUMP I TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS.L INTENDED USE TYPE OF WELL PROBLEM AREA NETRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation _—Approx. th ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of p H.P. State Work Done j Well Destruction ❑ iameter Sealing Material 5011 Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU N ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:= Residence_ Commercial_ Other i Number of living units: Number of bedrooms ._ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 7, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 160f oundation 2- D — Property Line SEEPAGE PITS Cl Depth 2 C Size 126 Number SUMPS ❑ Distance to nearest'. Well/,Q Foundations Property Line DISPOSAL PONDS ❑ - r 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califomia."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." N The applican ust call for all aquirad ins ctions. Complete drawing on reverse side. L� Signed Title: Date: ��_/ ` `97 FOR DEPARTMENT USE ONLY Application Accepted by / Date , Area ©/ Pit or Grout Inspection by Date + Final Inspection by Data 15 I r n! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 U 6",L f Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT'NO. INFO CASH 13 a£H 24{REV.1/B 51 S s EH 1425 i