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}� AJOPLIGATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �"^^''L (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 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. �.�C _ f Job Address ! + a F �. Cit G� 4 at Size �A PM e YCdwner's Name9do� Address � ! �\ J� _ Phone 40/9 \Contractor Address License No. Phone TY E OF WELL/PUMP: NEW WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C7XAGRICU SYSTEM R PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ES DISPOSAL FLD. PROP. LINE FOUNDATION RE W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS ❑ Industrial 17 Open Bottom C1 Manteca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack ❑ Tracy Type of ing Specifications 171 Public fl Other Cl Delta Depth of Grou eel Type of Grout _ I I Irrigation __Approx. Depth l I East n Surface Seal Install by _ Repair Work Done ❑ Type of Pump H.P. S Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 p Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 11` DESTRUCTIO INo septic system permitted if public sewer is vailable within 200 feet.I `� Installation will serve: Residence_ Commercial— Other- Number ther Number of living units: ._ Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number i 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 Di§trict. 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 mus call for all required inspections. Complete drawing on reverse side. , Signed;/9� S//� Title: `� / T Date: <cg-c.� j F DEPARTMENT USE ONLY ^^ � Application Accepted by Date la Area `'t or Grout Inspection by Date Final Inspection b �pr Date" (/"� tional Comments: 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 11 - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INIF MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j