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I � � APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA JA Telephone (2091-466-6 W �v�&�� I 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 des ribed. 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 Regui tions of the San Joaquin r Local Health District. I I , . /��Rriq �I L�S� L�F�+� CSG c i PJ� e� U l Job Address City of Siz PM q �7,�1 i Owner's Name * s j _ A6-dress c�[�37,, Aloft!E`t I_C� 1,`s,yjwvhone l;Contractor ` Address (�3/- Ac'a 14)C[� NJ�)f icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other C1 Delta Depth of Grout Seal Type of Grout_ _ I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ice, Depth i Filler Material (Below 50') ) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i 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/MfgF Capacity No. Compartments v PKG. TREATMENT PLT. ❑ Method of Disposal 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 i SEEPAGE PITS I ) 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, d 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust calwr7��4 ctiQns. Complete drawing on reverse side. �l'✓f/ /fir✓ lE� Signed X + Title: Date: ( FOR DEPARTMENT USE ONLY Application Accepted by } Date c) Pit or Grout Inspection by S Date Final Inspection by y Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 I INFO AMOUNT DUE ' AMOUNT REMITTED CK 4 CASH /RECEIVED BY DATE �P-EERRMIT'N�O, ..EH 1324(REV.I/n 51 > ?1 S ^ ?) ..f