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a 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA JUN 2 2 1$90 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. 5 Job Address Ci J %i _ City 3 Lot Size PM Owner's Name Address Contracto t' . 4-�- = Address ��25404at�' ( license No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR L7 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 ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Xpomestic/Private ❑ Gravel Pack F Tracy Type of Casing Specifications "1 Public Cl Other Fl Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.IZ.i— State Work Done t e- Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I J REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is >> Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Eli Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size r FILTER BED f J Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS I I Distance to nearest: Well _ DISPOSAL PONDS IJ Foundation--- Property Line 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 must c or all requir d inspections. Complete drawing onerse side. Signed X Lv - Title: Date: j� FOR DEPARTMENT USE ONLY Application Accepted by �/•" Date Ar Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Sik 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 AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 1AEV,I/Kyr .� U �Il