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r APPLICATION FOR PERMIT CkU� �/!- � r SAN JOAQUIN LOCAL HEALTH DISTRICT "r 1601 E. HAZELTON AVE., STOCKTON, CA -3 3 73 f Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (Complete in Triplicate) r ! 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. r � f Job Address v Cit Lot Size PM OwnerNAddress Phone 's ame �� , aol Contractor Address License No.��Picone G r TYPE OF ELL/PUMP. NEW WELL D WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Priv to ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation —..APprox'. Depth I 1 Eastern Surface Seal Installed by i r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — r TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION.I I DESTRUCTIONP(,.(No septic system permitted if public sewer is 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 y .,,;,SEPTIC TANK I❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.'❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE Is❑ No. & Length of lines Total length/size FILTER BED .i El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-1 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 rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 Calif rnia." I The applican t call all q d inspections. Complete drawing on reverse side. Signed X Title: Date. FOR D8JZTMENT USE ONLY Application Accepted by Date le'71� Area I / Pit or Grout Inspection by Da Final Inspection by�r L� Data �� L M 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 20}9, S1k., CA 95201 I� FEE i�AMOUNT DUE AMOUNT REMITTED CK RECEIVED f3Y DATE PERMIT Nb. w INFO CASH F35�- S -;Opt 9 T�30� I +.EH 1324(REV.t i H 57 3 EH 14-M