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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 3601 E. HAZE i ON AVE„ STOCKTON, CA NO W Telephone 52091 466-6781 N 0 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��{{�� y,•,,:a (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 CityLot Size PM Owner's Name40 . . 1ddress -- - C l& Phone Contractor Address' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El', 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 ELL PR WOBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ED Open Bottom ❑ Manteca 1*0L, of'Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack �►�`�.�❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout'Seal Type of Grout i I Ifrigation —_Approx, Depth I I Eastern Surface Seal installed by Tn' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter— - � Sealing Material (top 50') Depth Filler Material 18elow�50'11 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION [.I DESTRUCTION I fNo 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: Water table depth SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ + Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines - t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' I SEEPAGE PITS ('I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r hereby certify that I have prepared this application and that the work will bo 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 thefell ing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa M.. tion laws o alif nia." The app71-7 !�tcall or all re d_' coons. Complete drawing on rev r side. Signed Title: Date: FO P ENT USE ONLY �- Application Accepted by - Date� Area-_ z Pit or Grout Inspection by Date___..� Final,Inspection by Date AI J Additional Comments: �V f - l ] � �{��jr ❑ 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 I� INFO FEE AMOUNT DUE AMOUNT REMITTED C KSH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.I/x 51 EH 14-26