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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 v " .. (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. TMs 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. . e Jab Address Ci Lot Size/ X �f�fJ(J PM irr Owner's Name 6f• k l PhoneAddress• Contractor dr ss ! f A /g License No. a Phone I 9, TYPE OF WELL/PUMP: NEW WELL?❑ WELL REPLACEMENTX❑ DESTRUCTION ❑ 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 CONSTRUCTION SPECIFICATIONS a Industrial f EJ Open Bottom ❑ Manteca* t! Dia. of Well Excavation% Dia. of Well Casing 0 Domestic/Private ' ❑ Gravel Pack ❑ Tracy + Type of Casing Specifications 11 Public ,❑ Other; .k❑,Delta Depth of Grout Seal Type of Grout t I❑ Irrigation ---Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump HJ. — State Work Oone• ' Well Destruction ❑ Well Diameter Sea ng Material {top 50'1 1 # , Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑—REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Iavailable within 200 feet:l Installation will serve: Residence Commercial— Other r Number of living r units: Number afZledrooms i Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg y Capacity No. Compartments Jam" �. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line } LEACHING LINE �TNo&`Length of lines �' )pj length/size FILTER BED ❑ Distance to nearest: Well Foundation A Property Line SEEPAGE PITS ❑'Depth �i Size ! Number # SUMPS "{ � D,�,Distance to nearest: Well ! 10— Foundation� Property Line 3 DISPOSAL PONDS A� 1 Ey .I hereby certify that'd 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 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 ertifies the following: "I certify that in the performance of the work for which thisrmit is issued,1 shall employ Pe p y persons subject to workman's compensa- ii tion laws of California." I _ The applica must call for.all required inspections. Complete drawing on reverse side. Signed Title: bate: aFODEPA RTMENT USE ONLY7, ` t y Application Accepted byCILDate Pit or Grout Inspection by Date Final Inspection by pie , Additional Comments: 1 ❑ 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 95201FEEr INFO~ --A'fk7U T DUE� "AMOUNT REMITTED" ~ CASH .. RECEIVED Ely ;' DATE PERMIT-NO. • �jr + EH 13-24(REV.1/9 5) < p. C> EH 14-26 ! ' F