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r _ _ I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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., I 1i Job Address 1 �1l �1.� 91 V16-V -S 1�/ J�l�(o. City Lot Size �� 765 PM Owner's Name ` OV Address 544'1 14 I St"UPj one J177t7 7; . �.qq iIf f Contractor C41Y S Address �f I/Ml License No. lam...Phone a1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE OUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE O PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy"\ a of Casing Specifications ❑'Public ❑-Other ❑ Delia' 'Depth a Seal _Type of—Grout ❑ Irrigation --4pprox: Depth ❑ Eastern Surface Seal Installe 1 Repair Work Done ❑ Type of Pump H.P. State Work Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONo septic system permitted if public sewer is available within 200 feet.► '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 17!: Type/Mfg Capacity No. Compartments PKG. TREATMENT.PLT. ❑ 4 •�, h� Method of Disposal Distance to,nearest: Well Foundation Property Line3 " - 4 oper � I . r1 �-- LEACHING LINE ❑ No. & G gth of lines, Total length/size FILTER BED ID Distance' o nearest: " Well Foundation Property Line SEEPAGE PITS ❑ Depth -S ize Number SUMPS ❑ Distance 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the foflowing: "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 laws of California." The applicant mus call,for all reguirgO inspe 'ons. Complete drawing an reverse s'de. __ Signed X Title: Date: r FOR DEPARTMENT USE ONLY ,( Application Accepted by - Date 77 Area Pit or Grout Inspection by Date r Final Inspection by Date Additional Comments_: ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83.5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 3 INFO r1vAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. + EH13241REY.1/951 � EH t428 �[ 0 S