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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR 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 Jaaquin 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 V City Lot Size PM Owner's Name / L -� Address ?w Phone FYK— a 'Contractor — Address- '- — - License-No —Phone-� TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYS EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL`FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f Casing Specifications 1-1 Public n Other Cl Delta _ ._..__•..Dept —of Seal Y Type of Grout 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by ■ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ F Well Diameter Sealing Material (top 50') 3 t ' Depth t Filler Material (Below-50') TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIRIADDITION I 1 DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation-will serve: 'Residence— Commercials Other Number of living units: Number of bedroomw•---� �- -y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [1 Type/Mfg Capacity A d t No. Compartments PKG, TREATMENT PLT. ❑ t L Method of Disboqml Distance to nearest: Well A)1) Foundation Property Line S s� LEACHING LINE ❑ No. & Length of lines Tota length/size t FILTER BED ❑ Distance to nearest: Well g2 Prop rt Line SEEPAGE PITS i I Depth Size Number SUMPS 0 Distance to nea est. Well Foundation I 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. 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."r-..4-° + The applicant st-call for all r wired i pections. Complete drawing on reverse,side.` X' Signed X Title: * r' Data: � � �i ENT USE ONLY t 12 _ A plication Accepted by _" ,_"•'�t _ �Q / Date 7`� " �A�Area It or Grout Inspection by� °""'v Date ''1 o dFinal Inspection by � " Date -ef6 IV Additional Comments: ❑ Stk- 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 CAS RECEIVED BY O TE �}a PERRMII'�NO. +.EH43-244REV.1/951 � 7, 0 �U EH 14-28 r vo