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APPLICATION FOR PERMIT { �j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 G f J City Lot Size ] PM �J' (I Owner's Name ) 1 Address �T+�"�� Phone _C_ Contractor G(� �/ �Qx Address License No. Phase TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 C NSTRUC1110N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing, I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.4asinll Specifications . I FI Public ❑ Other Cl Delta Depth of Groin` e yl �`Gi Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal install ] Repair Work Done ❑ Type of Pump H.P, `t } State Work Done )V_fd_1_ (,�.} I Well Destruction ❑ Well Diameter Sealing Material ao ill { 1 Depth Filler Material (Bel ow S Jy TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 i0ESTFfUCT! I 1 (No septic system permitted if public sewer is ~�l available within 206 feet.) Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms ter, Character of soil to a depth of 3 feet: z--� {rl/arer)able depth SEPTIC TANK ❑ Type/Mfg Capacity_, \ ,��No. Compartments PKG. TREATMENT PLT. ❑ '* Method of Disposal p Distance_t�nea3t: _Wgll, „ _,F� rxdajon, _Propt;t --- d N LEACHING LINE ❑ No. & Length of lines `+( I >l N Dotal_length/size M FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di$trict. employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 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 tion laws of California." workman's compens re The applicant mus all or 11 requir inspections. Complete drawin on ev rse side. Signed X Title: Date: F EPARTMENT USE ONLY Application Accepted by Date Area 7 j Pit or Grout Inspection by Date Final Inspection by Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK R .ECEIVED BY DATE PERMIT-NO r-� CASH +.EH -24{REV. 14 EH tl-28 �•I ,