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JF K APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA N Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I (Complete in Triplicate) I 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 �5 �c9• City C Lot Size PM Owner's Name r�� !J >Et oL—Address L C __��L.f'� J'tU`G--Phone I P�Contraclor- cr Address License No- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. t Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public FI Other Cl Delta Depth of Grout Seal Type of Grout , t� I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ `I Repair Work Done [-7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBolow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR IADDITION I I DESTRUCTION (No septic system permitted if public sewer is ` available within 200 feet.) i 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 LI Type/Mfg 'VI o. Compartments PKG. TREATMENT PLT. ❑ _ A Method of Disposal Distance to nearest: ell o4 at r perty Line very'l av rlM 6�P rrtt cit LEACHING LINE ❑ No. & Length of lineswork. being roMnAtedr Irrstp size FILTER BED ❑ Distance to nearest:"` I. Fa n erty Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll 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 g q ea th Dj%tnct. 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 ust call for all required inspections. Complete drawing on reverse side. Signed X T �✓ Title: Date: l l F PARTMENT USE ONLY Application Accepted by Date L� 0" 5 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: F ❑ 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 INFO MOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. ♦.EH 14-21 IREV.1/851 2 ClD ,ter 3 EH 71-29 tJ V