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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZELTI 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 ` Job Address 1-7 •��T �U� �� City / o(vt Size PM Owner's Name C ��T� Address ___ - 'T�l Phone Contractor �� _. 2ddT Add,ess71�f� ��r ��License No.�G�oO��/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ s' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. ,. SYSTEM REPAIR ❑ OTHER © F DISTANCE TO NEAREST: SEPTIC TANK -SEWER,LINES DISPOSAL FLD. PROP. LINE j FOUNDATION y AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA \CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑.Open Bottom ❑ Ma iteca:>, Dia.of Well Excavation _ Dia.,of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy " Type of Casing Specifications ❑ Public ❑ Other ❑ Del tet+ Depth of Grout Seal Type of Grout k ❑ Irrigation ---Approx. Depth ❑ Eastern Surface S,w]Installed by -. } f ) Repair Work Done ❑ . Type of Pump .�f H.P. '--' State Work Done Well Destruction ❑ Well Diameter Sealing Material.{top 501 e:k Depth Filler Material (Below'501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,❑ DESTRUCTION ❑ (Nc septic system permitted if public sewer is ' v ii' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other '< Number of living units: Number of bedrooms Character of sail 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 LEACHING LINE k--No. & Length of lines Total length/size FILTER BED ❑m.,.-Distance to nearest: Well Foundation Property Line SEEPAGE PITS A� Depth `h �`� Size !!514P �� Number c Y v SUMPS ElDistance to nearest: Well ZifnI ;,r,, Foundation� Property Line DISPOSAL PONDS ❑ i y 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 laws of California." The applicant must ca or all required in pect)on plate drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY 7/2Application Accepted by Date' S Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-5781 ❑ Lodi. 369-3821 ❑ Manteca 82:3-7104 _ ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO -AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY —7 DATE PERMIT NO. + EH13-24(REV.t/a 5) r r EH 14-28 0 _a l ZSIeerio b �5� ,