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APPLICATIOWFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 _Q• ,.a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .,,,. ��`� ;1^+.a�;~ R •ri a d (Complete in Triplicate) N O `C to S 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. �♦ ( !�:r14AlI {Iw. =-L. 4 ` ��.F F•i P '� - � t r r i ,:. tiJ Job Address City Lot Size PM Owner's Nam "Address W�r "`--i� .:. Phone Contractor ' Address License.'No. Phone TYPE OF WELL/P MP: :NEW WELL ❑ WELL REPLACEMENT 0 f DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE F AGRICULTURE WELL OTHER WELL TS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ION SPECIFICATIONS ❑ Industrial 71 Open Bottomanteca Dia. of Well Excavate Dia. of Well Casing (� ❑ Domestic/Private ❑ Grav ❑ Tracy Type of Casing Specifications [ lgnl Ll Public Other ❑.Delta Depth of Grout Seal Y y Grout ❑ Irrig ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 'r Well Destruction ❑ Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I - t available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: - - Water table depth SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation'�" 1 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well -Foundation Property Line SEEPAGE PITS ❑ 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 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`.wbrkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the woik for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." - . ---+ , „ r '-:A- I The applicant�must call for all required inspections. Complete drawing on reverse side. Signed X_L1nt/�� a Z,1� Title:;.— a Date: 03-�75—�� OR KEPARTIMENT USE ONLY Application Accepted by Date 3 Area CO Pit or Grout Inspection by Date Final Inspection by . Date t!? Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca .823-7104 ❑'Tracy 835-6385 4, 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 " RECEIVED BY ' DATE PERM17'NO. a EH'1 -24#REV.t/n sl O EH 144-29 � "4