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G � APPLICATION FOR PERMIT � � SAN JOAQUIN LOCAL HEALTH DISTRICT "y i E. HAZELTON ON AVE. STOCKTON, CA 1601E �j Telephone (209) 466-6781 1" 1 PERMIT EXPIRES TYEAR FROM DATE ISSUED H�prL�N {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 rw�crial This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. n X �i? i' Job Address City Lot Size_ PM Owner's Name Vl}�h - l� Address Phone Contractor /13i ti of � Address License No. �Phone TYPE OF WELL/PUMP: NEW WELL, WELL REPLACE T ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �.=� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION F� ❑ Industrial ❑ Open Bottom 17Manteca Dia. of Well Excav tion Dia. of Well Casing X. �� Domestic/Private gave! Pack ❑ Tracy Type of Casing Specifications [1 Public rfl Other Cl Delta Depth of Grout Sea{ ype f.Grout I ! Irrigation p� �+.Approx. Depths ISI Eastern Surface Seal Installed by "r `r - Repair Work Done ❑ Type of Pump+' '.z_ H.P. State Work Done L1 Well Destruction ❑ Weil Diameter 11 _ Sealing Material (top 50'1 Depth �� __ Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) 6 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 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 SEEPAGE PITS l 1 Depth * Size Number f SUMPS Ll Distance to nearest: Well undation Property Line - DISPOSAL PONDS O - 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 suc)rlmauner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies the following: " certif 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 r all requir i cions. Complete drawing on reverse side. Signed X l' Title: date: R DEP RTMENT US ONLY Applica ' nn Accepted by Date +�� Area GZtSn " OCG` f/dam �C Jr-�f IfJ`7�Ia�i Date Pit ar t Ins tion y ate Fin inspection by_ Additional Comments:211 w UAoLk d E " + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH c + EH13.241IREV.i i H s1 1-3A, IZ �s EH 14-26 � S �.