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>_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR 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 C unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address A City Lot Size PM Owner's Name 'ry® 4,!T" Address - Phone Contractor is Address License No. Phone_ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑' O R L1,} DISTANCE TO NE REST: SEPTIC TAN_ K SEWER LINES DISPOSAL FL PROP. LINE FOUNDA AGRICULTURE WELL OTHE LL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTIO CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of avation Dia. of Well Casing s t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty f Casing Specifications 1-1 Public ❑ Other Cl Delta epth of Grout Seal Type of Grout I I Irrigation _Approx. Depth i 1 Eastern Surface Seal Installedby _ Repair Work Done 11 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Baiow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION bLLNo septic system permitted if public sewer is r ` available within 200 feet) 1� 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. LI Method of Disposal i Distance,to nearest: Well Foundation Property.Line t 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 Ll Distance`:to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ 1 11 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 Dii;trict. 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, i shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X J°L�i�rrrr � . , �'Y1r -r�� Title: Date:� L, FOR DEPARTMENT USE ONLY Application Accepted by p _—_— Date Area Pit or Grout Inspection by } Date Final Inspection by Date S 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 )NFO AMOUNT DUE µAMOUNT REMITTED CASH CK 11 RECEIVED 9Y DATE PERMIT-NO. • ♦.EH13-24(REV.I1H5) J -�1� 17,Z_ Z` 1.IZ TiEH 14-2$ V ! ! (((JJJ [J