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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 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 i 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. City Lot Size PM I Job Address —. �o polis -t-l.A Address _�--��f�``- -� _ Phone Oby� Owner's Name sr�.—-- - F Address r""` Uicense No `s` �+ Phone ��'" �l Contractor , TYPE OF WELL/PUMP: NEW WELL ❑ 1,"iWELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR t� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL° it OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing Domestic/Private E3 Gravel Pack C1 Tracy Type of Casing Specifications D Public ❑ Other l7 Delta Depth of Grout Seal Type of GrouE r t I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done Type of Pump sg H.P State Work Done 1 „ Well Destruction U Well Diameter Sealing Material (top 501 C Depth Filler Material [Below 501 — ( TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is \v available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet: Water tabled th f SEPTIC TANK 1 s. ❑ Type/Mfg CapacityILI P6Y'TREATMENT PLT. ❑ Method of Disp Distance to nearest: Well Foundation Property Line i f LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation --��Nvir�ONMENTAL HEALTH SEEPAGE PITS 11 Depth Size Number I FG SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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. %-Q .•.a'.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 applica all for aR-r quired inspections. Complete drawing o reverse sided :2,1 � Signe � Title: Date: , � FOR ARTMENT USE ONLY ` I Application Accepted by d Date �A. Area q Pit or Grout Inspection by 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE -AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. INFO +.EH 13-24 rREV.iins) �.5'�ar� C/ �� ,7✓ / EH 14.26 Air f --