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APPLICATION FOR PERMIT .S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ND r Telephone (209) 466-6781 1N.D �Q`CIIC vl 5-a AQ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W 14 (Complete in Triplicate) �� M`�5 �� ,�� i 5-b 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 I 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." I Job Address City I Lot Size PM Owner's Name" Address /�--��lfAvPhone �� Contract � Address �� License Na`76L��/ Phone "-7't�✓ 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing ii El Domestic/Private '1 ❑ Gravel Pack El Tracy Type of Casing Specifications k 'r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ii. --Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done © Type of Pumpr M- H.P. T _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth R 7Piller-Material (Belo'w 50') F F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: k Water table depth SEPTIC TANK �D Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ElMethod of Disposal ji Distance to nearest: Well Foundation Property Line i I , LEACHING LINE ❑ No. lit Length of lines t Total length/size a 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 a 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 becom8 subject•to•workman's•oompensation-laws-of Califomia." 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 applicwWTNust call for all equired inspections ti Complete:drawin§ bn reve sid Signed Title: a' s XQ Date: �P 16 87 FOR DEPARTMENT USE ONLY 5 1 b5- O Area rd� Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date�� A orvvt o Additional Comments: i ❑ Stk 466-6781" " ❑ Lodi 369-3621 ❑ Manteca 829-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l� I FEE AMOUNT DUE AMOUNT REMITTEDCASK RECEIVED BY DATE PERMIT` 0. INFO + EH 13.24(REV.t/a 51 � �4 3✓� . �7 EH 54-28