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` APPLICATION FOR PERMIT s s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`i ON AVE., STOCKTON, CA R> Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' ! (Complete in Triplicate) 7 i 1 I re; 1 rt 'j�•1 Si. Application is hereby made to he San Joaquin Local Health District for a permit to construct and/or install the work hereih,,deT66. `_ 11This 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 Oistrict. Job Address � '- so City Lot Size PM r Owner's Name Address Phone Contractor' Address 00 �r1� gym+ k��37Lic nse No. 4- Phone ��$i TYPE OF WELL/PUMP: il� NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �)(Uomestic/Private ❑ Gravel Pack LJTracy Type of Casing Specifications F] Public f J`O` ther la Delta Depth of Grout Seal Type of Grout - J I 1 Irrigation 1,..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. d �� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 N i Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial— Other I` Number'of living units: Number of bedrooms r Character of soil to a depth!of 3 feet: Water table depth SEPTIC TANK ❑ i Type/Mfg #Capacity t No. Compartments PKG. TREATMENT PLT. LI Method of Disposal . 3 Wistance to nearest: Well Foundation Property Line k x k LEACHING LINE ❑ 'No. & Length of lines r Total length/size FILTER BED ❑ II`Distance to nearest: .t Well Tr Foundation Property Line I SEEPAGE-PiTS ( I i'IDepth Size Number SUMPS El DISPOSAL PONDS ❑ J 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 a ent's signature certifies the following: "I certify ,.� �- 9 g g: '•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." II: The applicant must ca or all Irequ' inspections. Complete drawing on reverse side. Signed Title: Date: i R DEPARTMENT USE ONLY Application Accepted by .� Date A Area 2/ k Pit or Grout Inspection by ate Final Inspection by ate a2 l i Additional Comments: I� f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMO rNT DUE AMOUNT REMITTED' F 'CASH ck it RECEIVED BY DATE PERMIT'NO. a.EH 13-21 iFtEV.1iHsY EH 14-26 35 r ,IF i