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APPLICATION FOR PERMIT y 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 AddressCity of Size PM Owner's Name Address U dPhone L> V 66 Contractor/ t ddress u—Id— License No�J�Phone �4 Q 2 TYPE OF WELL/PUMP: NEW W%LC1 WELL REPLACEM T ❑ DESTRUCTION ❑ -PUMP INSTALLATSYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATEONAGRICULTU WELL OTHER WELL PITS/SUMPS _ INTENDE=D USE TYPE OF WELL. PROBLE ARE CONSTRUCTION SPECIFICATIONS ❑ Industrial �>El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public r ❑ Other Cl D. 'a Depth of GiouC5'eal' ""` '"" -..Type of Grout �° + I I Irrigation Approx. Depth I I astern urface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing Maten (top 50') G Depth Filler Material (Bew 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION f I (No septic system permitted if public sewer is j available wit 200 fee 1 Installation will serve: Residence_ Commercial_ Other `.� r i Number of living units: w Number of bedrooms.0 l/./J J1 Character of soil to a depth of 3 feet: Water table depth = SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal F Distance to nearest: Well t/ pr I!Feundation Property.Line LEACHING LINE ❑ No. & Length of lines A Tota gth/size FILTER BED ❑ Distance to nearest: I ation Pro rt{r ins I SEEPAGE PITS 11 Depth p Size Number SUMPS 1.1 Distance to nearest: Well `""' Foundation Property Line DISPOSAL PONDS ❑ 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. 1. 1 :1 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, l shall employ persons subject to workman's compensa- tion laws of California." The applica must call for squired inspections. Complete drawing on reverse side.. Signed X F Title: � Y r ~ Date: x �FQR� DEPARTMENT USE ONLY Application Accepted by —FtDate �f ; Area 13 Pit or Grout Inspection by Date -Final Inspection by Date 1_124 L Additional Comments: ❑ Stk 466-6781 to 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 RECEIVED BY DATE PERMIT'NO. ♦ EH 18-241pEy.tins) —7V17/ — EH 14-2e n