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ry t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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. el r7 r Job Address a' City ✓ of Size PM J -Owner's Name �' Address /. ' �3 Phone ,54 Contractor Address License iVo. Phttf[ r Z TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f ' 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: Sj PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ^❑yManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/.Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N f`1 Public I 17-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation !-Approx. Depth I i Eastern Surface Seal Installed by f Q1 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 I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer?is t i available within 200 feet.) r f Installation will serve: 'Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth o`f 3 feet: Water table depth ,t SEPTIC TANK ❑ Type/Mfg- iS ; Capacity,_ No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal ;Distance to 66rest:, Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to neareta'N Well��__. - Property Line L � € SEEPAGE PITS I I Depth Size Number I SUMPS L1 Distance to nearest: Well tl Foundationr- `•; ._ Property Line } DISPOSAL PONDS j ❑ 1 t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin4county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ,+ s – 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 insuch manner as to become subject to workman's compensation laws of California."Contractors`hiring or sub-contracting signature certifies the following: "1;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 must call for I required i spec 96s, Complete drawing on reverse side. Signed X Title: r �� Date: A p f EPARTMENT USE ONLY i _ Application,,Accepted`by Date Area I Pit or Grout Inspection by ,Date Final Inspection by I JO Dat t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-31321 ❑ Manteca .823-7104 ❑ Tracy 835-6385 I Applicant ,Returnall copies to: Environmental Health Permit/(Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 C $ FEECK , INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t EH 1324(REV.r/e 5) EH 14-26 [/ p-1141 K 3