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r APPLICATION FOR PERMIT C C SAN JOAQUIN LOCAL HEALTH DISTRICT a � ` 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hi ieby 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. i a Job Address © t City` Lot Size /��1 PM 4 k Owner's Namete: S Address OQ z `�/ Phone Contractor4�`�t r "�3{/y L� Address `L— License No. Phone /-6L I TYPE OF WELL/.PUMP: KNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLO. PROP. LINE ( er FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDUSETYPE OF WELL PROBLEM AREA- .CONSTRUCTION SPECIFICATIONS ❑ Industrial 1 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packj ,_ ❑Tracy Type of Casing Specifications f'i Public ❑ Otherti r❑tDelta r Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 1.1 Eastern— � Surface Seal_ Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work:Done Well Destruction ❑ Well Diameter # Sealing Material (top 50'1 i Depth t° Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION`( 1 REPAIR/ADDITION 1 1. DESTRUCTION^iNo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence „_Commercial_____ Other t Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg I Capacity .No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size"' , FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 t SEEPAGE PITS 1 I Depth Size I _ Number SUMPS ❑ Distance to nearest! 1Nell Foundation Property Line w DISPOSAL. PONDS ❑ 4 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 Di3trict. E 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 became 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 woIrk for which this permit is issued,t shall employ persons subject to woikman's componsa- tion laws of lifornia." The applicau t call for equired inspections'Complete drawing on reverse side. Signed X V. Title: r Date: I - i ; FOR DEPA Tf1AENT USE ONLY t s Z! l Application Accepted by Date Area ` Pit or Grout Inspection by Date Final in ection by Date Additional Comments: i d _I ❑ 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 v s { ltA INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE' PERMIT'NO. n + ASP EH 13.24(REV.iiHs) p` FH 14-26 I