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APPLICATION FOR PERMIT ..� SAN JOAQUI.N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA N-0 k+3J2q11 n Telephone {209} 466-6781 .M pC_ PERMIT EXPIRES'1 YEAR FROM DATE ISSUED �'�'�*►�L,� f D Y, ` ..., - ^;• {Complete in,Triplicate} Application is hereby made to the San JoaquinLocalHealth 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 Distr`iccrt Job Address T Cityl �/" Lot.Size 71 pNl W Owner's NameWAddressPhone /f -.3j� ' fP Contractor �� Y Address ry License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST TION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYP!E"OF WELL"'''--PROBLEM- A "":CON$TRUCTIO CATIONS . ❑ Industrial ❑ Open Bottom ❑ Manteca i ell Excavation Dia. of Well Casing N ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Casing Specifications ! ❑ Public ❑ Other elta Ddpth of v'ut Seal Type of Grout ❑ Irrigation �4ppro pth ❑ Eastern Surface Seal In ;Iled by Repair Work bone ❑ Ty Pump H.P. ¢ `i State Work Done Well Destruction ❑ ell Diameter Sealing Material'["top Depth, Filler Material {Below-.50')._-_ - TYPE OF SEPTIC WORK: .NEWT INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION V (No septic system permitted if public sewer is s 1 #available within 200 feet.► Installation will serve: Residerice_ Commercial_ Other I Number of living units: } Number of bedrooms # I Character of soil to a depth of 3 feet: . ' Water table depth SEPTIC TANK ❑ Type/Mfg r y Capacity l No Compartments PKG. TREATMENT PLT. ❑ f 3 Method of Disposal # i � 1 Distance to nearest: Well Foundation Property Line } LEACHING LINE ❑ No.'& Length':of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' 1 v SEEPAGE PITS O Depth size i Number ( SUMPS LIDistance to nearest: Well - - —Foundatio — n — Property Line DISPOSAL PONDS ❑ r 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. - ' 1. 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." (nSigned nt mus r all required inspe 'ons. Complete drawing on reverse side. Title: Date: ti L 7 r Date: s OR•DEPARTMENT USE ONLY � Application Accepted by Date Area Pit or Grout Inspection y Date Final Inspection byf—, t�- s;v Date �� 4 Additional Comments: ❑ Stk 466-6781 EJ Lodi 369-3621 [DMant 823-7104. ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009;Stk., CA 95201 j FEE -7 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED Sy DATE PERMIT NO. a EH1 -24IREV,iiH51 .Q EH 1428 1lrr��-��ffff�UUUJ '