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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES VYEAR 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 descri ed.Thh pplication 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. "C Job Address 7 �' "`—'� • City Lot Size PM N Owner's Name Z' D Address _ Phone Contractor W ALTH)kLL� Addressicense No. 30 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L t DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t"'""-SEWER-CINES'—s""'" "'""'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS x INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION'SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 4 ❑ Domestic/Private ❑ Gravel Pack L7�Tracy Type of Casing 'r 4 Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal __ Type of Grout I I Irrigation —.-Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') f Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.7. REPAIR/ADDITION l I DESTRUCTION IU{ ! tic system permitted if public sewer is ° -y available within 200 feet.) Installation will serve:w 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �R Foundation Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 4� Property Line DISPOSAL PONDS ❑ S I hereby certify that f 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 }iealth 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 fee ifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ p@r""sons subject to workman's compensa- - tion of Califo j The applican st call all re wired�spe ns- mplete drawing on��reve��rse��si^^de. f I Sign Title: —Date:, i i LRTMENT USE ONLY `�] i Application Accepted by .� (A, Date 2-3 37 ` :Are_a _ Pit or Grout Inspection by Date Final Inspection by Date ` 7 } Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3671 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/.Services_1601-,E._Hazalton_Ave.., P.O.-Box.2009,.-Stk.,.CA 95201.__-.- FEE 5201.._,,, _-._ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"HO. +EH13-241REV,t/x51 �•[�(V� Lr� `�"`�rf�.