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r� 'APPLICATION FOR PERMITL� SAN JOAQUIN LOCAL HEALTH DISTR �3 �� k. ( � 1601 E. HAZE.I ON AVE., STOCKTON, � F Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUE� �� 2 �, (Complete in Triplicate) I i'LV 0' '.' _ t�1p1 it 1 12V;C:ES 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. ® t Job Address `�_ ce-� City Lot Size PM • Owner's NameAddress -7-4. _ Phone V Contractorddres4 �•4� A-A� .g License NJ 7-3 -Phone ^7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIt0ETUR�-INELL`.,�—` OTHER WELL PITS%SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing Rr Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ( Specifications ❑ Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ I i Irri ation - A r g .�.. pprox. Dept l Eastern Su ace Seal Installed by _ i Repair Work Done CJ' Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material {Below 501 f" i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPA)R1ADDITION [ I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line •} t LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 Di?;trict. , Home owner or licensed agent's signaturelcertifies the following:`1 certify that in the performance of the work for which this permit is issued, I shall not , employ any person in such manner as tofbecome 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." a The apptican ust c=required allpections. Complete drawing on Averse side. Signed r[le:'^ Date: y I FOR DEPARTMENT USE ONLY Application Accepted by t I Date Area Q I Pit or Grout Inspection by Date Final Inspection by - Date f Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY DATE PERMITNO. + EH14-241REV.r/x5f tn 1r3 J G �j9,��c EN 14.28 f o b 1