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APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT N0 1601 E. HAZELTON ON AVE., STOCKTON, CA N,0 Telephone (209).466-6781 1 G 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 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... .fi`t,':rl'1' y, j 3, CrtyS Lot Size PM Job Address �L. z �+ 4 < rte// Z S �i Address `"+�J"��' - �j 7? S K fV+ _ Phone L�� C� Owner's Name 4� ContractorAddressLicense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES ------ --"DISPOSAL.FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 „, 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } i Specifications ❑ Domestic/Private. El Gravel Pack S ❑ Tracy Type of,Casing Type pe of Grout Ll Public ❑ Other El Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .. _H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material litop 501 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ViNo septic system permitted if public sewer is �* yf 11vailable within 200 feet.) Installation will serve: Residence Commercial i?.Other- Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: T 3 ' —Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ElMethod of Disposal Distance to nearest: Well Foundation Property Line j •rI LEACHING LINE ❑ No. & Length of lines. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V w. SEEPAGE PITS ❑ Depth Size Number SUMPS ElDistance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 i 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."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 California." The applicant at II for all ired inspections. Complete drawing on reverse side. I Signed Title: � /� n Date: i R DEPARTMENT USE ONLY I ^7 j Application Accepted by Date ��"� f — Area Pit or Grout Inspection by Date Final Inspection by��"�"Z Uo,-o .Cris Dat JS-'�a I Additional Comments: n j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83"385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 b-6-civ FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED 6Y DATE PERMIT N0. INFO CC_ * +"EH la-241REV.11651 a �/ EH 1428 I' �.i_