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r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA rQ1D Wzl�t-w+^9-� Telephone (209) 466-6781 [� Q } 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 C i my Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. cJ ` City Lot Size X 3 O'D PM Job Address f Owner's Name �A �• Il Address /ys �+� s J D11 t1 _ Phone Conlractar Address License No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAtNK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEf.L PROBLEM AREA CONSTRUCTION SPECIFICATIONS LiIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rS ecifications El Domestic/Private 171 Gravel Pack El Tracy Type of Casing P s fl Public f 1 Other f-1 Delta Depth of Grout Seat Type of Grout i I I Irrigation —..Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia! (top 501 Depth 1 Filler Material (Below 50 ` TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is -skailable within 200 feet) installation will serve: Residence! Commercial Other Number of living units: Number of bedrooms r r a Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,I, -. , Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance+to clearest: Well Foundation Property Line SEEPAGE PITS I l Depth If Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 14 " l 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Cd a�� '" Signed X � - Title: ., ez Date: a7 {� FOR DEPAR USE ONLY - (�;+\�,( Date _, Application Accepted by Area Pit or Grout Inspection by Data Final Inspection by Dat�9 j/� 1 Additional Comment 7 `t`! �`� -/ey ❑ Stk 466-6781 ❑ Lodi -3621 Manteca 823-7104 ❑ Tracy 835-6385 �(r� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEPERMIT NO. INFO �[ r EH 13-24IREV.IIn51 �7-.3 - - EH 14-26 v