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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. 44d-� e, Job Address �+� ( City C Lot Size �G PM Owner's Name �t +�/ �S Address Phone Contractor ErJ Address ( pe l 11�Y �� ! License No; /-$`4 _PhoA TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `4. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION e AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ 7 ❑ Industrial ❑ Open Bottom 17Manteca Dia: of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. F] Public C1 Other 11 Qelta Depth of Grout Seal Type of Grout _ I Irrigation �Approk. Depth I-k6astern Surface Seal Installed by Repair Work Done ❑ Type of Pump a H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing'Material.(top 50'1` Depth ~` Filler'Material (Below'501 TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted it:public sewer is available within 200 feet.) Installation will serve: Residence�Co_mmercial_ Other Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ¢t� r � Method of Disposal Distance to nearest: Well Foundation Z Property Line ! LEACHING LINE S No. &ieng'th of dines 11/-r7 �T Total length/size FILTER BED ❑ Distance to nearest Well Foundation /a Property Line, -� SEEPAGE PITS 1 ) 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 rules and regulations of the San Joaquin Local Health D%trict. , 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." `'rhe applicant must call for aff r aired i spec tions Complete drawing on reverse side. •Signed X Title`. ��[ _�� Date: S d < ix• t I f1l FOR bEPARTMENT USE ONLY Application Accepted by Date `� Q Area Pit or Grout Inspection by Date Final Inspection by 5 Date 27 b Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Returnoall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE x- AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. a EH 13-24 1REV.I/Kb) ��Q q � £H t4-26 l