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y� Y { APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 �,L• / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A ` (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 Lo I Health District. f �o 1\ Job Addresses N�� _.'- �© � City Lot Size PM 1 Owner's Name. Address Phone ontractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D PROP. LINE E FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS A CONSTRUCTION SPECIFICATIONS K- ❑ Industrial Y ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifications f'7 Public Other {1 Delta Depth of Grout Seal Type of Grout — 0 1 Irrigatio -Approx. Depth I I Eastern Surface Seal Installed by - -fteo.6-ir Work Done - ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR)ADDITION l I DESTRUCTION (No septic system permitted if public sewer is 1v ailable 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 } 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size. Number SUMPS ❑ 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 taws, and It 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 call for all required inspections. Complete drawing on reverse side, i r Signed X Title: Zi-,) Date: F DEPARTMENT USE ONLY !� Application Accepted by Date-2) / Area ry Pit or Grout Inspection by Date Fi I Inspec.on by t/ A o�-C�G Date J � ' 1 �r Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 11101 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Cie I FEE OUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO ' ♦ EH 13-24 MEV.1/Y:sl �7[ S �� •—+� f �//