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r APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 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 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. Job Address 2' 'x' `� � �` CityS i��-ry Lot Size PM Owner's Nam �R-� ��%-Address �V _ Phone T / �-7 3 Contractor Y Address License No. Phone TYPE OF WELL/PUMP: NEW VaLL ❑ - - WELL REPLAC ENT, ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ F ` SYST REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULT E WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM ARCONSTRUCTION SPECIFICATIONS r F 0 Industrial ❑ Open Bottom ❑ Manteca f ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy { Ty of Casing _ Specifications ❑ Public ❑ Other" r r ❑ Del Depth o Grout Seal Type of Grout V ❑ Irrigation �pprox. Depth ❑ stern Surface Sea nstalled by MRepair Work Done ❑ Type of Pump H.P. State Work Done p , Well Destruction ❑ Wel( Diameter- Sealing Material (toll 50'} U Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION E] REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is f available 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: Water table depth SEPTIC TANK Type/Mfg Cap ityNo. Compartments PKG. TREATMENT PLT. 171Method of Disposal Distance to nearest: Well F daton Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i 3 SEEPAGE PITS 0 Depth% Size Number SUMPS ❑ Distance to nearest: Well oundation Property Line { -"DISPOSAL PONDS ❑ + f� 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." nt must call for all re inspections. Complete drawing on reverse side. l _ Sig d � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ,Date -C-0-2 Area 0,3 Pit or Grout Inspection b Date Final Inspection by Date f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca &2h104 ❑ Tracy 835-83135 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ' CASH RECEIVED BY DATE PERMIT'NO. + EH 14-2e(REV.F/651' I EH 1426 Cv '