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APPLICATION FOR PERMIT ". SAN JOAQUIN LOCAL HEALTH DISTRICT I � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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.THs 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 ` City 5_A:P �CiCot Size PM Owner's Name &C)," ddress Phone l w�� Contractor's Name c5icense No. Phone TYPE OF WELL/PUMP: NEIN WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ,ISD SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD.T.._,� PROP. LINE FOUNDATION AGRICULTURE WELL 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 1 D Domestic/Private ❑ Gravel Pack Tracyr Type of.Casing Specifications ❑ Public ❑ Other %41DL Delta Depth of Grout Seal Type of Grout M ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 4 H.P. �`�'� - State Work Done I Repair Work Done ❑ Type of Pump ��}i.P. � .•J�-1�� Ti � Well Destruction ❑ Well Diameter Sealing Material Itop 501 J � Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 1 REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is Q t available within 200 feet.) Installation will serve: Residence_ Commercial— Other kNumber of living units: Number of bedrooms ' Water tabl .de th Character of soil to a depth of 3 feet: ` P 4 SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments G PKG. TREATMENT PLT. 0 ( Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING-LINE `C].`No. Length of lines I Total length/size FILTER BED ❑ Distance to nearest: !Well ou`ndation• Property y Line fi - y SEEPAGE,PITS ❑ i Depth Size E G fa Number `I SUM��PS �Q Distance to,nearest: Well � ? Foundation^...- i� Property Line DISPOSAL�PO�DS ❑ �'' i 'n,r _ r I hereby certify that I have' repared this application and that the 'ork will he-done-in'ici cordance with San Joaquin county ordlnances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agerrt's signature,certifies.the following: 'll cern=that in tl e� formance 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- pensation 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." j i I The applicant m fo all r it d inspections. Complete drawing on reverse si e. Signed I Title:�d! _ date: I y i FOR DEPAR ENT SE ONLY Application Accepted by +`` ^ I Date Area t ! Pit or Grout Inspection by tDate Fnal Inspection by Date ' Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369-3821 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK _ RECEIVED BY DATE PERMIT"NO. INFO CASH EH 7428 + (REV.t0/Enl 5. C? ��/`r �'� � •r