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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 s. c PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . ..y. r. '(Complete in,Triplicate) q ' 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. .Lot Size m� J �PM` I Job Address t) G1 .+w City Owner's Name 1 mmmL' w Pars Address SI� Phone - Contractor c,e4 Address License No. Phone .! TYPE OF WELL/P NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN ON ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK' ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL7 OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S TIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Sped Is ❑ Public ❑ Other ❑-Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by tl, Repair Work Done ❑ Type of Pump H.P..--� - _ State Work Done Weil Destruction ❑ Well Diameter Sealing Material liop 501 , Depth ""—- Filler Material (Below-501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC 1N septic system permitted if public sewer is av lable 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 Capacity No. Compartments PKG. TREATMENT'PLT. ❑ Method of Disposal 'A Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_- Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 r rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents 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 f 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." 1. ` r The applicant must call for all required nspections. Complete drawing on reverse side. Signed X r V Title:' ; Date: FOR DEPARTMENT USE'ONLY 2 �} Application Accepted by Date [J / Area Q� -- Pit or Grout Inspection by Date Final Inspection by' Dal I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6365 Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE+ AMOUNT.REMITTED '. CA H RECEIVED BY DATE PERMIT-N0. INFO '+ EH 1324(flEV.1/e 5} EH 14.28 ' r._/cc✓// `J -+""^' ✓r (D