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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 ocal Health District. w i' S s ly c+/ //� City � � Lot•Size ?S�� / 1 Job Address � 5; _ PM ;q C c i Owner's Name FF IT� Address C/ a ' 1SF ft C–Ar� - Phone yr18V_7e9 f Contractor ` Address �7 f S- 5��4� P�� License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C; DESTRUCTION ❑ PUMP INSTALLATION ❑ c '�SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATIO AGRICULTURE WELL OTHER WELL 4 PITS/SUMPS INTENDED USE TYPE O WELL PROBLEM AREA CON UCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom anteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing °" Specifications ❑ Public ❑ Other" ❑ D Depth of Grout Seal Type of Grout ❑ Irrigation __._1pp�o D Eastern ace Seal Installed by ( �1� Repair Work Done [IType of Pump H.P. State Work Done_ w Well Destruction ❑ Well Diameter : Sealing Material (top 50'l .� Eller Material (Below 50'1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is "J 0 available within 200 feet.) Installation will serve: Residence_:Commercial— OtherE Number of living units: Number of bedrooms ' f n Character of soil to a depth of 3 feet: '_. Water table depth v / SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments PKG. TREATMENT PLT. ❑ F /Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line 1 SEEPAGE PITS ❑ Depth Size TNumber E SUMPS ❑ Distance to nearest: Well Foundation, Property Line DISPOSAL PONDS 0 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 71fo ail re ired inspections. Complete drawing on reverse side. Signed # � �� Title:' A�w ' Date: �/ t FOR DEPARTMENT USE ONLY i Application Accepted by I Date Area D /R Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 17 Lodi -3621 ❑ Manteca 823-7104 11 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. f INFO � �/�. Q•-� ,..[� + EH 13-24 1REV.I I K 57 �0 I////ppp�•[[[�� ' EH 14-28 G I