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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r t 1 (Complete in Triplicate) k 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 F 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 II Local Health District.., I l Job Address 3 (J f CCity O Lot Size JQ��(�. r PM i� Owner's Name Sisty lie Address 1S Q 6 Phone .Contractor. c� Zr Address License No, Phone 1' . TYPE OF WELL/PUMP: ;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'c PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Dome$tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications MPublic _ n Other ❑ Delta Depth of Grout-.Seal Type of Grout.. I I Irrigation __Appro+. Depth I I Easterner Surface Seal Installed by ' Repair Work Done _❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'17 Depth 4 Filler Material (Below 501 : r TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION i l DESTRUCTIO (No septic system permitted if public sewer is I vailable within 200 feet.). k Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms a` Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distancelto nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t - FILTER BED ❑ Distance'to nearest: Well Foundation '^– Property Line SEEPAGE PITS I Depth I _Size Number SUMPS 0 Di&tancb'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1� 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." 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, I shall employ persons subject to workman's compensa- tion laws of California." f The applicant must call for all required ins tions. Complete drawing on reverse side. �,S_igned X S Title: Date: — 169 1f FOR DEPARTMENT USE ONLY CApplication Accepted by L Date 41 Area Pit or Grout Inspection by w Date Final Inspection by ck� Date O U Additional Comments: h-2-1 _69 ---- ❑ Stk 466-6781 ff Lodi 369-3621 ❑ Manteca 823-7104 _ ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 .1 INFO AMOUNT DUE�'' AMOUNT REMITTED CA K H RECEIVED BY DATE PERMIT'NO. +.EH 13-24 tr1t:V.t i 11 sl EH 14-28 35