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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZE 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. r�V,r� Job Address 0 -S City. Lot Size PM . f pf Owner's Name Address 2 O Phone Contractor Address /26 f til' ajw� License No.14"_ J -Phone! �� TYPE OF WELL/PUMP: — —NEW WELL-0__..-- 'WELL`REPLACEMENT-❑ ----DESTRUCTION-•❑ --- - --- �• f PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. r PROP. LINE FOUNDATION AGRICUL URE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation ''Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications M l Public FI Other n Delta pth of Grout Seal Type of Grout _ i I Irrigation --Approx. Depth 11 East n S ace Seal Installed by Repair Work Done ❑- .Type of Pump H,P. State Work bone Well Destruction ❑ Well Diamoter Sealing Materi I it 50') Depth Filler Material (Below 50') t. i TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR./ADDITION I l DESTRUCTION f I (No septic system permitted it public sewer is u. available within 200 feet.) Installation will serve:"Residence + Commercial ther { i Number of living units: Number of bedrooms Character of soil to a depth of:3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg m Capacity 0 a No. Compartments 4 PKG. TREATMENT PET. ❑ u Method of Dios Distance to nearest: Well0sioundation Property Line� I LEACHING LINE ❑ No. & Length of lines /r, Total length/size L( , FILTER BED ❑ Distance to nearest: Well- � oundation 0 : Property L' e a � SEEPAGE PITS I ] Depth 2 %J Size Numbers Of `+ r SUMPS L1 Distance to nearest: Well 1� Foundation J Property Line DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andT 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 comi)ensation 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 compens@- tion laws of California." d i Thea Lica must call all require ins pp ` q inspections. Complete drawing on reverse side. Signed X Title: .-.(° %' Dater t a FOR DEPARTMENT USE ONLY Application Accepted by Date Area 2 t ' Pit or'Grout Inspection 6y'— ""Date—""`"---'"`Final Inspection by! Date Additional Comments: ❑ Stk 466-6781 ❑ 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 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH C.—RECEIVED BY ` DATE PERMIT NO. -,c-.+EPi'13=24'IREV-rrxs'��--..,,r..«-- "�O-,,..-.art - ..,. - .•`-�/��0 �-.�- ... EH 1 4-28 `