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APPLICATION FOR PERMIT SAN JOAQU.IN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781. —1 ISA i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i�tsc�pat. R1 (Complete in Triplicate) " N0 WRQ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described..TNss application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "' '' ,,. +w �� Job Address �� tp . ' r �4; r.` v . � City Lot Size PM Owner's Name'r�,Kt� -T Address�''`� -C+o Li �, Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑j' DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ��11A`LFLD._ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE R LINES PROP. LINE FOUNDATION AGRIC TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA" ON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pa. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type Casing Specifications ❑ Public ❑ Other ❑ to —Depth of rout Seal Type of Grout ❑ Irrigation �pprox, Dept ❑ Eastern Surfa_Surface Sea Installed by Repair Work Done El Type of Pum H.P. State Work Done Well Destruction ❑ Well Di eters - -•=Sealing Material (top 50') Depth Filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial— Other �Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKType/MfCapacity No. Compartments PKG. TREATMENT PLT. ❑ ► Method of Disposal Distance to neare • Well Foundati Property Line P LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: W Foundation Property Line SEEPAGE PITS ❑ Depth - Size - Number SUMPS. O Distan o nearest: Well tindation Property Line DISPOSAL PONDS ❑ 1 " 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 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."Contractors 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." mu call for all quired inspections. Complete drawing on reverse side. Signed i Title: Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection by 12 Date , Additional Comments: ❑ 5tk 466V81 L3Lodi 369-3621 ❑ Manteca -71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health PermitlServicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE I INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED.BY DATE PERM17'NO. +EH 13-24(REV.t/e5) ,i. EH 14.29 pp S+c7..?. r