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J r p APPLICATION FOR PERMIT e SAN JOAQUIN LOCAL HEALTH DISTRICT •�'�-iC iLCix� 1601 E. HAZEL i-ON AVE.,.STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPI.RES'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 Joaquin County.Ordinance.No:549 for sewage or No. 1862 for well/pump and the Rules and Regulations ofdhe San Joaquin Local Health District. -j".j yCYa {„britt i. Y:'S�. - h w Job Address lN7 City Lot Size X PM }Owner's Name/g". LBctliwS — Address ��y I/f��r'9 __ Phone Y 2— Contractor Address License No. Phone_ TYPE OF WELL/PUMP , ., NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O . - -PUMP INSTALLATION°❑ a SYSTEM REPAIR ❑ OTHER:❑-t 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 , CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca. - .---.Dia. Of.Well Excavation..- i Dia. of Well Casing ❑ Domestic/Private F1 Gravel Pack ❑ Tracy Type of Casing I Specifications ❑ Public Li'Other ❑ Delta .,Depth of Grout Seal Type of Grout p. ❑ Irrigation _ ---Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Donee ❑,r` Type of Pump H.P: State Work Done _ { Well Destruction ❑ Well Diameter Sealing Material (top 50`) "Depth r Filler Material (Below 501 e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: Residence�. Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ^ f. Water table depth SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments ti PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE r ❑ No. & Length of lines Total length/size kkk FILTER BED ❑ Distancerto nearest: Well Foundation Property Line f SEEPAGE PITS ❑ Depth Size v Number SUMPS .-E],-Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D - ; 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 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." The app7�- us II fpr all requi inspections. Complete drawing on reverse side. �( Signed LY,,J Title: ��' Date: ! i FOR DEPARTMENT USE ONLY /J Application Accepted by Date r Area Pit or Grout Inspectionby Date �Insp`ection by Date � A k I Additional Comments: G 7 S -w l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Retur all copies to: Env o mental Health Permit/Se rvi es 1601 E. zelton ve., P 0. Box 2009,Stk., CA 01 ew _ FEE -.AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT NO. INFO j CASH �/ rQ `f t EH 13-24(REV.I/'H 5) -# f J �p^ �� .1 Ink EH 14-29 fff !J fff///��— s �• .. .. .r -•r-- -._ ._. _.. 6.. r