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APPLICATION FOR PERMIT ,. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAS, 1` Telephone (209) 466-6781 _ L•w;F�, -';1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E h rSat,,, . IComplete 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. f -M f '`�! Job Address ? .�� Lot PM City Owner's Name - Y 1 �`g- Addresl__"� 7�/ C�'� 'p" '� Phone Phone — TYPE es, A (00 J 6 r_56,� �'S-3Li e se fQo. _� Z Contracto ,, ��-+�� ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION & SYSTEM_ REPAIR ❑ OTHER E1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of'WdII-Excavation Dia. of Well Casing V Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public LI Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth ( I EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 0J"3— State Work Done zr ," -t 4L"441'fo f„ Well Destruction ❑ Well Diameter xSealing Mate ial (top 501 Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION-1 1 DESTRUCTION l I (No 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: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Q� LEACHING LINE ❑ No. & Length of lines Total length/size / FILTER BED ❑ Distance to nearest: Well Foundation Property Line + i SEEPAGE PITS 11 Depth Size �A= aNurnbor ' + SUMPS L-1 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. t x r 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 call for all requod inspections. Complete drawing on reverse side., Signed XS Title: Date: F RDE RTMENT USE ONLY Application Accepted by Date Area �a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: r ' ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 8234104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 Z Hazelton_Ave..,_P 0._Box-2009,-Stk-CA-96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH (� ♦.EH 1324(REV.iin5) �� r( g EH 14-28