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j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'"TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR 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. Job Address Qtr[7 Cit��XLLot Size PM Owner's Name Address L!fa' �rJ?• �i cSJUf� S� Phone y�61' � �- � �� 5-f rt. 'Fr2n 6 i I Contractor �� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ElSYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation ,..Approxi Depth [.1 Eastern Surface Sedl installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ f Well Destruction ❑ Well Diameter Sealing Material (top 50') V Depth ( Filler Material (Below 501- TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I 1 DESTRUCTION- .(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: REater table depth SEPTIC TANK ❑ Type/Mf C ac, Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal Distance to nearest: Qar�I �R 111`�'Qio� . ' . . ° f;t. i°�y�{erty tine work being J 01 � tri S LEACHING LINE ❑ No. & Length of lines Total lengi size r -nyiron—n - T,I y FILTER BED Q Distance to nearest: l �'Fburi�8tti n OMS rt Line INumber SEEPAGE PITS l I Depth + Size SUMPS Ll Distance to nearest: Well .— TFoundation- Property Line t DISPOSAL PONDS ❑ i I 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 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." Contractors hiring or sub-contracting signature cartifies 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 applicant must call for all required inssWtions. Complete drawing on reverse side. Signed - r L Title: Date: + FOR DEPARTMENT USE ONLY Application Accepted by Date - Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: -•--- -- _ -- Q Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEF AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + INFO ��fl �' X96 z �36 +.EH13-24IREV.tie51 �g � EH 14-26