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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Y1 Telephone 12091 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 Ordipance N .549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t�G PM Job Address"� •! !" City Lot Size a / Owner's Name ddress t \_Phone �j Contractor res License No./ Phone TYPE OF WELL/PUMP:- NEW W LL-❑ ,A WELL REPLACEMENT.71. DESTRU TION PUMP INSTALLATION ❑ i SYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "❑ Domestic/Private 0 Gravel Pack ❑ Tracy -<Type of Casing—. Specifications 171 Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth l I Eastern Surface Seal installed by j Repair Work Done ❑ Type of PumpH.P'= ""'" "`'"` tate Work one V Well Destruction [71Well Diameter Sealirig Material [top 501 De th _ Filler Material (Belo 11 P TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION IFf DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) " Installation will server `Residence L! `Commercial � ther Number of living units: Numher of bedrooms t Character of soil to a deptA of 3 feet: - -----t' Water table depth SEPTIC TANK ❑ Type/Mfg" Capacity A 012No. Compartments PKG. TREATMENT PLT. FI ... ,;,Method of wposal Distance to nearest: Well�` _- Foundation Property Line Ile .. LEACHING LINE ❑ No. & Length of lines _ Total length/size ' 44 FILTER BED Q Distance to nearest: Well 'Foundation d Property Line _.:.___ SEEPAGE PITS 11 Depth J Size Number � �^} SUMPS Ll Distance to nearest: Well Foundation Property Line 91 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, 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 u c r all reqym nspections. Co plate drawing ori.rever a side. Signed X en Title: [_ Date: r l R DEPARTMENT USE ONLY r Application Accepted by Data 9 tiZ Area # Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OW Stk., CA 95201 - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 1 -24 iREV.i/K S) i EH 144-2a