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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT o 1601 E. HAZE T ON 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. 4 Job Address City Lot SizA ! +L v PM - 41yf D Owner's Name Address __ Phone en Contracts ss License N PM +:✓ 4 TYPE OF WE L/PU P: NEW WELL ❑ WELL REPLACEMENT Lr DESTRUCTIO - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications F1 Public 17 Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth i l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction. ;❑ - Well Diameter Sealing Material Itop 501 1 ' Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I V REPAIR/ADDITION l I DESTRUCTION I. 1 INo septic system permitted if public sewer is - �-�-�--�- -�-------- --�available within 200 feet.I Installation will serve: Residence L Commercial_ Other t t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 47) Water Sable depth SEPTIC TANK ❑ Type/Mfg Capacity4 No. Compartments PKG. TREATMENT PLT. ❑ Method of D' os (a Distance to nearest: Well Foundation Property Line- I a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ~ Foundation __._ Property Line SEEPAGE PITS j ( I Depth Size t- Number SUMPS Ll Distance to nearest: Well I-At") Foundation n Property DISPOSAL e- 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 Dihtrict. 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 j 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 { The applicant us I f 11 requ0drs/etions., Comp) ing on a"side.' } < .i' . *+ .Signed XTitle: Date:f fi/ D OR DEPARTMENT USE ONLY } '' l Application Accepted by I Date ` Area Pit or Grout Inspection by Date Li Final Inspection i Date /1 1 W Additional Comments: ry' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71.04 ❑ Tracy '835-&385" _ Applicant - Return all copies to: Environmental Health Permit/Services:1601 E. Hazelton Ave., P.d. Hoz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO .. /� CASH ER 3-24 ^7Q.�� 03)"1�1 (0-]-71 EH 14-28