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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA e� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 County 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 ��5� / -O-fi�P �2-2�� City Lot Size 6 zy x61ew PM �//II �� Owner's Name �1i. Address mfr rz.-P Phone Contractor ddress License No. Phone AWM4 TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPW❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGO ULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS LlIndustrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private [D Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public ❑ Other elta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. pept ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is � - - /��--, available tthifn 200 feet..))�/� Installation will serve: Residence_ Commercial_ Other Le C/ 'ec;i Number of living units: Number of bedrooms O 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 Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ ('1 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, ander 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." Contractors 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." The applicant mi call for all require inspections. Complete drawing on reverse side. (('�� Signed Title: G� Date: 1"_ `b 1 ��/��" FOR DEPARTMENT USE ONLY Application Accepted by ` Date k-- Area Pit or Grout Inspection by Dat@ inal Inspec ion by Date 2 Additional Comments: Kip '7 1tJ ❑ 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 2(109, Stk., CA 95201 FEE v� INFO AMOUNT TDDUE AMOUNTREMITTED CK 0 CASH RECEIVED BY 1 DATE PERMIT'NO. EH1&2I IREV. EH 1420