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APPLICATION FOR PERMIT ? SAN JOAQUIN LOCAL HEALTH DISTRICT � ! 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 } l�j PO PERMIT EXPIRES TYEAR FROM DATE'ISSUED l t u j (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. (1 -Job Address ��T I l-�/►'>L y City t Size PM -�Owner's Name / Address -� PhoneZ at s Contractor icense N J Phone t 760 TYPE OF WELL/PUMP: NEW WELL ❑ V, �,rWECE REPLACEMENT,`❑ 1r DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA.IR ❑ OTHER ❑ D ,..d.. . ..� kST,ONCE-TO"NEAREST:"SEPTIC�T;41VK SEWER-LINES--- D15P05AL'.'FLD-_.- ... . PROP'LINE FOUNDATION —,AGRICULTURE WELL OTHER WELL . PfTS/SUMPS V 4r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f f'l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout e I I Irrigation —.Approx. Depth I I Eastern Surface $..I jnst8lted by_L Repair Work Done ❑ Type of Pump W.P. f State Work Done ' Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material (Below 50,) TYPE OF SEPTIC WORK: NEW INSTALLATION [.] REPAIR/ADDITION l 1 DIESTiRUCTIOru -INO septic system permitted;if public sewer is t available within 200 feet.) Installation will serve: 'Residence j Commercial_ Other f -- Number of living units: Number of bedrooms Character of soil to a depth of 3 teat: Water table depth . # SEPTIC TANK ElType/Mfg Capacity - - =+ .No-Compartments # PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property line g'g ri i r LEACHING LINE ❑ No. & Length of lines Total length/size r FfLTER BED L1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line e -DISPOSAL PONDS ❑ 4 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 certify that in'the performance of the work for which this permit is issued, 1 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." 1 The applicant- st-call.for.all-required-inspections:Complate,drawing om reverse-side:— Signed Title:--E4,14 41 tOi mt.. ..d��.._.._,.� Date: 7 A FOR DEPARTMENT USE ONLY f Application Accepted by Date3� 1= � Area I Pit or Grout Inspection by Date ,Final-inspection by- ` Dater Additional Comments: 1R t LfQ! V ,[_< ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 535-6385 V Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 j FEE INFO AMOUNT DUE AMOUNT R@MITTEO CASH RECEIVED BY DATE PERMIT' �\ +•EH 43-24 fREV.iinsis - �f EH 14-28•• u�Ey C! .