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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� f ,,.�, 1601 E. HAZEL T ON AVE., STOCKTON, CA Icli � Telephone (209) 466-6781 y e PERMIT EXPIRES TYEAR FROM DATE ISSUED N� lo►�r (Complete in Triplicate) ��►v , 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. Job Address ,z—z-t-.-'[Q A Y►/�ALP,5v" 9 A r City, Lot Size PM JOwner's Name // '""� 11 6,,,&�/rddress 31w/I�/f xigr:4�13 hone i Contractor C �� Address J-,4,4f License No. Phone .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE IR 1710THER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG ULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARXCOUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaWell Excavation Oia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyCasing Specifications f'1 Public Cl Other ❑ Delta rout Seal Type of Grout-- 1-1 I I Irrigation =._Approx.A"Depth I I East Surface Seal stalled by _ �1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50') . :STYPE OF SEPTIC WORK:- NEW"INSTALLATION-IJ.-REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vaiiable within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soii'to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of-lines Total length/size "j FILTER BED ❑ Distance to nearest:' Well Foundation Property Line 4 1 4 SEEPAGE PITS I I Depth 'Size t Number SUMPS Cl Distance to nearest: Well Foundation Property Line S DISPOSAL PONDS ❑ t 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. 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 m st II for all required 'Hsps t' n Complete drawing on reverse side. f3 , r � w ' Signed X Title: � JN4�'/Q Date: C�1 F EPART.MENT USE ONLY Application Accepted by Date %- - Area 101 Pit or Grout Inspection by Date Final Inspection by 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.0-Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.1/H sl 077ls r 00 rcltO----) —3304 EH 14-28 -