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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA k , Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) r k 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. rl c Job Address City Size PM Y Owner's Name Address Phone044Y - 6799 Contractor!f Ld ess ` ( � erase No,f ? Phone TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout—.-- I rout _I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter 1 Sealing Material (top 50'1 •""� Depth Filler Material (Below I, \� r } TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION IV DESTRUCTION I I INo septic system permitted if public sewer is ± F available within 200 feeL)1 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 r Distance to nearest: Well4 Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeilFoundation Property Line S GE PITS I ] Depth iz Number SUMPS Ll Distance to nearest: Well Foundation Property Line ISPOSAL 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 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�tl all r quit i tions- Complete CLEawing nn�yerside. - �. - • Signed X Title: date: w a FOR EPARTMENT USE ONLY Application Accepted by $ Data Area 1D Pit or Grout Inspection by Date f=inal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 p� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 IN b AMOUNT DUE; AMOUNT REMITTED g CK 4 CASH RECEIVED BY DATE PERMIT'NO. r EH 13-24[REV.I/H51 / (' ' EH 14-2a - 1