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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r "n t- (Complete(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. t Job Address 1A 1� l N1City Lot Size PM Owner's NameAddress `f l Phone 3— 49-71 Contractor's Name L L" L k, icense No. _� lJ � ,13 —l—,S61 /_f �" Phone �/60 6 TYPE"OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout }' ❑ Irrigation �pprox. Depth Eastern Surface Seal Installed by r Repair Work pone Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI-R/ADDITION ❑ DESTRUCTION ❑ fNo 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments {� PKG. TREATMENT PLT. ❑ Method of Disposal L/ Distance to nearest: Well Foundation IZ? Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation- Property Line t � SEEPAGE PITS ❑ 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 laws, and ` rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, I shall not i employ any p manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th ollowing: ,I ce 'fy that in the pert mance th work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws California." The appri an must II r requir -ins o ete drawin tse side. U Signed 'Zt�,,� it a* * `f FOR EPARTMENT USE ONLY r Application Accepted by Date1�k _ Area / Pit or Grout Inspection by Date Final Inspection by Date "�(fes Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ 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 ♦ 71FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED'BY DATE PERMIT"NO. CASHy+ EH 13-241REY:10/1 EH 1428 FA3 5 33 0