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i r 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. Job Address T�7r�- !x__J�'\ ��,. - _ City ` r Lot Size PM Owner's Name ddress Phone ff i [ t Contractor { �" t �F� d`ess "` la License IVo� Phone 32 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REFfLACEMENT ❑ DESTRUCTION . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED U5E1*}` '�- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ lndustriaF ❑ Open Bottom...... ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t 1-1DomestielPrivate ❑'Gravel Pack" ""w"!'❑`Trecy'"*'"'" Type of'Casing Specifications l`k �,ublic �� ❑.Other. CI Delta Depth of Grout Seal Type of Grout _ a--•. I, I I Irrigation Approx. Depth l 1 Eastern Surface SealInstalledby - Repair Work Done ❑ Type of Pump HSP '"�"`�- _' State Work Done Well Destruction ❑ Well Diameter Sealing Material itop:50 Depth Filler Material {Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION i.1 DESTRUCTION f (No 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 Aepth 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 ❑ No. & Length of lines TA al length/size'"'- ` FILTER BED El Distance to nearest Well Foundation kProperty Line I. ��JJ SEEPAGE PITS I I Depth � Size �� Number � SUMPS Ll Distance to nearest} We11 Foundation : Property Line DISPOSAL PONDS ❑ I " 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 ofthe San Joaquin Local Health District. Home owner or licensed agent's signature certifies"the following: "I certify that in the performance of.thework 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 applica ust all fpr all req 'red in pectionsz Complete drawing on reverse side. �.,- Signed XL. Title: v�L X� Date: • ++w1e+e FOR DEPARTMENT U5E ONLY / ,rl Apph'cetion Accepted bDate U tea Ly tq' Pit or Grout Inspection"b Date final Inspection by ate Q' Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104racy 835-6385 Appilcant - Return all copies to: Environmental Health Permit/.Services 1601 E. azelton Ave., P.O. Box 2019, Stk., CA 95201 z If FEE AMOUNT DUE A OUNT REMITTED j CK RECEIVED BY DATE PERMIT_NO. INFO i + EH 3241REV.�/n5) 1 - V� � EH 4 r �