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APPLICATION FOR PERMITa ,t �1 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. �flit szj�,a_ City Lot Size L PM Job Address✓ Owner's Name ddress Phone`s `o`w 9_0 66 Contractor - Address f �r �""' ~s License No Phone��P �� .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ --" PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .'DISTANCE TO NEARESTr 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 1-1 Domestic/Private ❑ Gravel Pack ;.,D Tracy Type of Casing Specifications 1`I Public ❑ Other` `� [--] Delta Depth of Grout Seal Type of Grout I I Irrigation ___Approx. Depth„ { 1•Eastern Surface Seal Installed by - Repair Work Done` ❑ Type of Pump, ; H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW-INSTALLAT N I J-,REPAIR/ADDITION DESTRUCTION l 1 Wo septic system permitted it public sewer is w + available within 200 feet.) Installation will serve: Residence Fe Coinmerciai Other Number of living units: ','`Number of bedrooms Character of soil to a depth of.3 feetWater table depth SEPTIC TANK ❑ Type/Mfg 41 Capacity No..Compartmenis PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE X No. & 'Length of lines_ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 applican must call f r 1I requi inspec' ns. Complete drawing on reverse ide.' [] �� Signed X r �' Title: Date: , L7,. 6 y 14� F DARTMENT USE ONLY C� Application Accepted by G� *w ' Date `f Area Pit or Grout Inspection by Date Final Inspection by Date F Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK 4T R IVIED BY DATE PERMIT NO. EH 13.24 p4o� EH f4-26 V