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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT � � . 1601 E. HAZEL T ON AVE., STOCKTON, CA �� u'-b-r r „�„- Telephone (209) 466-6781 4I3 C,�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r � (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address G Ci Lot Size PM p e- Owner's Name Address �-� r hone �^� I Contractor � f Address 1 License No��15__'S2{�Phone � d43j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . - e" DISPOSAL FLD, 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 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth Eastern �S rface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ` State Work Done Well DestructicnOQ ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D (No septic system permitted if public sewer is available within 200 feet.) rn j Installation will serve: Residence— Commercial— Other W e 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. ❑ r i. 4 �' Method of Disposal Distance to nearest:"' a"Well Foundation Property Line LEACHING'LINE ❑ No. & Length of lines "` 3• Total length/size FILTER BED ❑ Distance to nea est: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line a —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. Home owner or licensed agents 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."Contractors 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." f i The applicant m st call for required inspections':Complete drawing on erse side. G I Signed {` " Jitle,' `v, /Y�d-�✓ Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Q C Date Tr `S Area Pit or Grout Inspection by Date Final Inspectionb Date; f' Additional Comments: -� I el ❑ Stk 466-6781 L7 Lodi 369-3621 VManteca 823-7104 D Tracy 835-6385 Applicant- Return all copies to: Environmental Ralth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY Q DATE PERMIT NO. CASH + EH 1326 PREY. /a 5S EH 1426 4'5- b 1r��y lias u � �S p,Q