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i /[ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. ] Job Address �� / '�4�"/r'`�' City Lot Size PM Owner's Name /y/yU/�v ��//4L-llL�ddress `S� /�GU�A Phone Contractor Address License No. hone TYPE OF WELL/PUMP:(. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCN PUMP INSTALLATION ❑ SYSTEM REPAIR El HER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ElIndustrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications ElPublic ElOther ❑ Delta Depth of Grout Seal Type of Grout El — Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ElDESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) ln'ta will serve: Residence_ Commercial_ Other Number of living u Number of bedrooms Character of soil to a depth of 3 fee. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to of Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 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 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 AC�must call for all require in pections. Complete drawing on reverse side. Signed X 'v\ -'L'"`-a' Title: Date: FO EPARTMEIlIT USE ONLY Application Accepted by Date _Z Ja Area e � (, Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: of 4t y_zz z4 C � /_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE t INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. +EH 13.24(REV.1 i e 51 EH 14.28