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APPLICATION FOR PERMIT" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. .y Job Address To`? /' City Lot Size PIVI i Owner's Name �I F Address Q-7 +' Phone a Contractus Address/121�/��r�r�1—�- License fro. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ..I FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public f1 Other ❑ Delta Depth of Grout Seal Type of Grout—.—.—. I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done Type of Pump„4,a _ __ H.P. State Work Done, Well Destruction , ❑ Well Diameter, Sealing Material {top 50'1 L AE4 101, Depth Filler Material (Below 50') '� r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer iso Q available within 200 feet.) Installation will serve: Residence Commercial_ Other r ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg ' Capacity No:-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well .Foundation Property Line j LEACHING LINE ❑ No. & Length of tines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest:. Well Foundation __._ Property.Line - -...r I DISPOSAL PONDS ❑ i 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 DiIttict. 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 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 must call for all required inspections. Complete drawing on verse side. Signed X _ Title: /Y+�Cl Date:. i FR f7 ARTMENT USE ONLY Application Accepted by Date — y+ p Y Pit or Grout Inspection by Date Final Inspection by Date/ �I d 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ♦.EH1324(REV.I/n 5k EH 1429 ✓ d] �� -+\ n ! I?S �o` f