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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone: (209) 466-6781 PERMIT EXPIRES TYEAR 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 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: A r1 Job Address S kcr 0 —:v(,. City Lot Size PM Owner's Name ddress Phone � t r_ s Contractor `Address �C-L. License N� �w Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP(INSTALLATION ❑ SYSTEM REPAIR ❑ OT R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE roc FOUNDATION AGRICULTURE WELL 0 ELL PITS/SVJMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS {{vV^1 ❑ Industrial ❑ Open Bottom I Manteca D" ell Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications 111 M Public ❑.Q er~� ,K'- a Depth of Grout Seal Type of Grout I Irrigation _ApproX. D r t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of mp H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r r Depth Filler Material !'Below 501 TYPE OF SEPTIC WORK: /NEW eNSTALLATION 1 REPAIR/ADDITION l I DESTRUCTIONo septics tem permitted if public sewer is available witt in 200 feetA x Installation will serve: Residence_ Comme ial_ Other Number of living`units: ,Number of bedi- oms Character of soil to'a depth of 3 feet: f Water i able depth SEPTIC TANK ❑ Type/Mfg Capacity No. Co partments PKG. TREATMENT PLT. ❑ Methoc of Disposal Distance to nearest: Well rounadtion Property Line A LEACHING LINE ❑ No.;& Length of line _ total length/size FILTER BED ❑ Distance to nearest: Well Fouridation Property Lin r v SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well roundation Property Lin DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicatior and that the work will be done in accordance with San Joaq iin county ordinances, state laws, and rules and regulations of the San Joaquin Local Hei Ith District. Home owner or licensed agent's signature certifies he following: "I certify that in the performance of the work fort which this permit is issued, I shall not employ any person in such manner as to become su lect to workman's compensation laws of Califo=Ma." ontractor s hiring or sub-contracting signature certifies the following: "I certify that in the performant'e-of_thye work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." '�ti�- The applicant st call for all required i ctio Complete drawing on re rse side. Signed X Title: ' Date: 4f_ X91 FOR DEPARTMENT USE ONLY Application Accepted by �� Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: v ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ID Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201FEE . INFO AMOUNT-DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERM11"NO. a.EH 13-24 MEV.r/H51 EH 14-29 I -,