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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209).466-6781 .., t v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t 3 (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: Jab Address City Lot Size & 2 PM Owner's Name Address / 5 �� -C,�1( Phone ~ r Contractor Address License No. Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \v) DISTANCE TO NEAREST: SEPTIC TANK SEINE INES DISPOS FLD-- -- PROP. LINE FOUNDATION AGRICUL URE WELL O WELL PITSLSUMPS °t t INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTI SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Di of Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy T Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing,Material,(top 50'1 Depth FilleFMaterial WeloW501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenbe_'_"-Commercial—_. _Other — Number of living units: Number of bedrooms ih Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . Property Line r i LEACHING LINE ❑ No. & Length of lines ': Total length/size +, • .: FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Q Depth Size Number SUMPS 0 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 agents 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." e e app i nt must call for II requiredinspections. Complete drawing on reverse side. ..,� Signed /, Title: �� ice+ Date: - -w" (/tom FOR DEPARTMENT USE ONLY '*. V 4 Application Accepted by Date Area r• s r-' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 i ❑ Tracy 835-6355 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f - FEE AMOUNT DUE AMOUNT REMITTED ,ti RECEIVED BY DATE PERMIT'NO. INFO - s + EH13-24(REV. /85) l�C, �,� ..l_ EH 14-26 �•J 1