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APPLICATION FOR PERMIT 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5'� City Lot Size PM --�A _ _C , Owner's Name /�A Address Phone �, r Contract o Address e—o 6; I&19&,Zs ��31_oicnse N,;65>U 96 2-- Phone—'Ir3s TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑f OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public H Other F] Delta Depth of Grout Seal Type of Grout I 1 Irrigation _..Approx. Depth I I Eastern FFe Surface Seal Installed by _ Repair Work Done Type of Pump „_441t� H.P. fly State Work Done I Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 _ y t TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l 1 DESTRUCTION I I INo 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: Water table depth 1 SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments _�PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size "'`FIL-TER BED 0 Distance to nearest: Well Foundation Property tine SEFPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line i y DISPOSAL PONDS ❑ 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, a rules and regulations of the San Joaquin Local Health Ditrict. 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 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." The applicant must c r all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Dater Area Pit or Grout Inspection by Date Final Inspection by Date 2 Additional Comments: 11 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY HATE (P�EyR�MIT'NO. ♦.EH13-241REV.I/H5) EH 14-26 + ��