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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CAS Telephone (209) 466-6781 rr PERMIT EXPIRES TYEAR FROM DATE ISSUED d Lr (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 describe . 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 ... aid�� S�� 7y� City Lot Size PM Owner's Name ��».�� 9 J Address c- / Phone 3 � Contractor Address License No. Phone T PE OF WELL UMP: NEW WELL E WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK 'SEWER LINES' ' 'DISPOSAL FLD. ' PROP. LINE FOUNDATION AGRICULTURE WE " OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE REA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy 'Type of Casing Specifications r`7 Public f-1 Other ❑ Delta h of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I EasteSurface al Installed by _ i Repair Work Done ❑ Type of Pump• H.P. f --.State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 t. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1'1 DESTRUCTION I (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 A Character of soil to a depth of 3 feet: r Water table depth V 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 I I Depth Size y Number SUMPS LI Distance to nearest: Well .Foundation Property Line DISPOSAL PONDS ❑. T 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 t 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 G 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." f The applicant t call for all required inspections. Complete drawing on reverse side. Signed X S/ Title: Mw Date: — U DEPARTMENT USE ONLY 1�Application Accepted by Date Area Pit l Pit or Grout Inspection by Date Final Inspection by Date - Additional Comments: —1 - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 I❑ Tracy 8'3k-638-5' rY Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE`. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•No. + EH13-24[RfY.r/n57 - -3s• 3�. �� 1�� _Bob Ir-W-S r�&I EH 14-26