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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address !�✓�-' � 1�-'�� `� — City Lot Size PM Owner's Name Address �O �'t Phone �� L cense No.�f�� - : PhoneE-- 2`_ � Contractor 1[�. /#-� Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �K_ SYSTEM REPAIR ❑ OTHER ❑ "DISTANCE-TO NEAREST: SEPTIC TANKL ` SEINER LINES "DlSP05AL�FLD PROP-LINE— T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bott6 n D Manteca Dia. of Well Excavation Dia. of Well Casing YDomestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications FI Public Cl Other 1 ❑ Delta Depth of Grout Seal Type of Grout . I I Irrigation --Approx.,bepth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump j H,P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material jtop 501 I Depth Filler Material Welow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O I available within 200 feet.) Installation will serve: Residence, Commercial_ Other Eitf Number of living units: Number of bedroomsCharacter of soil to a depth of 3 feet:' Water taSEPTIC TANK ❑ Type/Mfg Capacity No. ComPKG. TREATMENT PLT. ❑ Method oDistance tonearest: Weil Foundation Property Line r Total len th/size LEACHING LINE ❑ No. & Length of lines g FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number . - SUMPS t_:_ �, Ll., .Distance to nearest: Well FFoundation Property.Line ,r DISPOSAL PONDS El �� pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this a # he San Joaquin Local Health DRarict. regulations o t rules and g q 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 1 The applic s�callfor��eqed inspections. Complete drawing o verse side. Signed �� Title Date: FOR EPART I�T USE Y Application Accepted by t Date / Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ♦,EH 13-24)REV.1/n 51 Q f I EH 14.28 lip 1 i