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ii I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J ( [. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I N (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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address T7 Ju- City Lot Size PM I ' Uly� s T Owner's Name _</! M f� ' Address Phone Contractor �! Address License No. Phone TYPE OF VVEI_L/PUMF.'IV NEW WELL ❑ WELL REPLACEMENT, ❑ -DESTRUCTION ❑ PUMP INSTALLATION ❑ • SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 111 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 171 dther Fl Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - LD L� Repair Work Done ❑ Type of Pump H.P. State"Work Done _ P Well Destruction ❑ Well Diameter Sealing Material Itop 501 J Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION i,I DESTRUCTION (No septic system permitted it public sewer is �i available within 200.fe.et.M Installation will serve: Residence'_"Commercial____W 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 i FILTER BED' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number. -- SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ii 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 'k rules and regulations of the San Joaquin Local Health District. ; Home owner or licensed agentls signature certifies the following: "I certify that in the performance of the work for which this permit is issued, !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 comps sa tion laws of California." jy .The applicant must all forallrequired inspections. Complete drawing on reverse side. Signed X % Title: Date: II i� FOR DEPARTMENT USE ONLY " Application Accepted by LJ1 fA —.Date - 3- Area II Pit or Grout Inspection by Date Final Inspection by `E �� i Date Additional Comments: �tl' . IN t �� d �O )V1 — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �-Qr EEH 13-24 H 14 2g IREV.I/H 51 t ,