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APPLICATION FOR PERMIT ff ` SAN JOAQUIN LOCAL HEALTH DISTRICT% w 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 8 {Complete in Triplicate) �,,'��S�QLOAQ�/IV Application is hereby made to the San Joaquin Local Health District for a permit to construct ani)/or install the work herein die'sEril�d�T `� cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 fa*wllpuA? nd the Rules an gulations a tiW�.A aquin Local Health District. � ��a� Job Address 0 l �t l P City Lot Size PM 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, 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." The applicant ust cail.for all require spections. Co plate drawing pn reverse sid9n Signed Title: _ems[ Date: 1111,7134 DE ART NT SE ONLY—E r ,I3'�' Application Accepted by !' ' Date �� Area 19 Pit or Grout Inspection by / Oat�a3 Final,) spectio by Date Additional Comments:VAP0��o �y` [ G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 J ` Applicant - Return all copies to: Environmental Health Permit/Services 1601'E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13.24 (REV. 101931 EH 14-28 FEE INFO O AMOUNT REMITTED K Owner's Name A Address Q Phone 99 32Z Contractor's Name =License No. Phone TYPE OF WELL/PUMP: =;=L IV WELL REPLACEMENT ❑ 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 AREA CONSTRUCTION SPECIFICATIONS El Industrial 10 El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing P,Domestic/Private VGravel Pack deoTeracy Type of Casing__ pre. Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal JrO� Type of Grout ❑ Irrigation --Approx. Depth ❑ 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size -Number SUMPS❑ w Dis_tance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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." The applicant ust cail.for all require spections. Co plate drawing pn reverse sid9n Signed Title: _ems[ Date: 1111,7134 DE ART NT SE ONLY—E r ,I3'�' Application Accepted by !' ' Date �� Area 19 Pit or Grout Inspection by / Oat�a3 Final,) spectio by Date Additional Comments:VAP0��o �y` [ G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 J ` Applicant - Return all copies to: Environmental Health Permit/Services 1601'E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13.24 (REV. 101931 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. ' J -A