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t x � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l_ (Complete in Triplicate) 0('7—t-1-0— (� Application i`s-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. Job Address City Lot Size PM tLt?� Owner's Nam Address Phone ltl Contractor Address ��. icense No. Phone 2 TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMEN6 ❑ DESTRUCTION ❑ ` 'PUMP INSTAL•LATIONSYSTEM REPAIR OTHER ❑- --�»- +-� - - DIST.ANCE TO..NEAREST:.SEFTIC TANK_ SEW.ER_LINES DISPOSAL FLD.. _.LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , i� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications ' I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout XInigation _.-Approx. De th { I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. ,�0State Work Done ,. Well Destruction ❑ Well Diameter Sealing Material p(top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I i Mo septic system permitted if public-sewer is available within 200 feet.) Installation will serve: Residence_ Commercial , Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:' . . SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � f Distance to nearest: Well foundation Property Line LEACHING LINE Cl No. & Length of lines +; - Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EI 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 DRarict. Home owner or licensed agent's signature certifies the following: "I certi,�y 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 Derformance of the work for which this.permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ' ' ^� The applicant mu all for all r quir pectio . Complete drawing on re se side. ♦ r �• r.r 4 Signed X Title: Date: DEPARTMENT USE ONLY p ' Application Accepted by Date �"—� Area Pit or Grout Inspection by 1!r Date Final Inspection by &-.-* Date 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE'S AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r.EH 13241REV.ti K51 EH 14-26 s _ I