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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA f 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 51-" . City &4Lot Size PM Owner's Name & rj I9 srhC",. Address ` Phone ' J c Contractor 1 Address 1! License No, 4Zi� Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El— PUMP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A N RUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca of a vation Dia. of Well Casing E) Domestic/Private ❑ Gravel Pack ❑ Trac Specifications n Public [7 Other Cl Delta epth of Grout Seal ype of Grout _ I I Irrigation _.-Appr Depth t I Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done .y Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 t TE OF SEPTIC WORK; NEW INSTALLATION I 1 f?I r•A!R/ADDITION ( I DESTRUCTION (No septic system permitted it-public seweks ' available within 200 feet.) Installation will serve: Residence_ Commercial— Other " I Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method sof Disposal Distance to nearest: Well y Foundation Property Line LEACHING LINE Cl 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 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 l rules and regulations of the San Joaquin Local Health Di§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." 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 applican ust call for a!I required insppictions. Complete drawing on reverse side. Signed X Title: _ `� ��r Date: r 01 FOR DEPARTMENT USE ONLY i Application Accepted by T — Date .. r Area Pit or Grout Ins = a �/ J peciion Dae r Fin I Ins action >ay Date _ f Additional Comments: r. ❑ Stk 466-6781 Q 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 CK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ///P]]]E/R�MIT'NO.//�� +.EH t4-29 3-241REv.i/xsl S L 66IM ��!!!� 'J �( �� [r/i EH 1UUU J u t