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APPLICATION FOR PERMIT SAN JOAQUINJLOCAL HEALTH DISTRICT A ' 1601 E. HAZELTON AVE'. STOCKTON, CA A j 4c� Telephone 1209)"466-6781.1. Gw fur' t't'+ PERMIT EXPIRES.�l YEAR FROM DATE ISSUED Y y ' t',y- � {Complete in Triplicate] Y1A +_ Application is hereby made�_A. oraqum Local Health District for a permit to construct and/or install the work herein described.This application is r. 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., 4 � Job Address Lot Size - PM Owner's Name Address `v. �. vt r`"�'e"'"��►� Phone Contractor --/Address License No. Phone TYPE OF WEA /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIS DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU ITU E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA"M C41NSTRUCTpe4 SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom' "` '❑ Manteca Dia. of Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty f Casing Specifications ❑ Public ❑ Other ❑ Delta epth f Grout Seal I Type of Grout ❑ Irrigation ---Approx. Depth ❑ Easterm ¢ Surface eal Installed by Repair Work Done ❑ Type of Pump h State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is E -.,,Y available within 200 feet.) Installation will serve: Residence_____. CO mercial `�-Other r j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth .SEPTIC TANK Type/Mfg f� Capacity No. Compartments PKG, TREATMENT PLT.`❑y 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines F Total•lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation # Property Line SEEPAGE PITS Depth Size 1 Number SUMPS ❑ Distance to nearest: ' WeII 1 Foundation Property Line DISPOSAL PONDS ❑ k Ij € 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. Ao'' " 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." 11 The applicant my#t call for all rejwf Complete drawing on reverse side.. F Signed _ '� ° Title:�: � ,��`��~ Date: i ! © I FOR DEPARTMENT USE ONLY ` Q Application Accepted by Date ` _ v Area F Pit or Grout Inspection Date Final Inspection by r Date Additional Comments:`► ❑ Stk 466-6781' ❑ Lodi 369-3621 VManteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH1324(REV.r/as) EH 1428 ✓ C/"L / /� !