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APPLICATION FOR PERMIT l ✓ " SAN JOAQUIN LOCAL HEALTH DISTRICT J� 1601 E. HAZELTON AVE., STOCKTON, CA �✓ Telephone (209) 466-6781 �) 1 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. Inh Add,. 3.L rr�� n q 00 & !'d �. AAr L.- . City 5(�"t AVo Lot Size PM 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 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 Califomia." 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 must call for all required inspections. Complete drawing on reverse side. Signed x7�ltfZ Title: 5 J� Date: Application Accepted by Pit or Grout Date Z -2- 3 - V 7 -Area /40 Date Final Inspection by Additional Commdhfs: ❑ Stk 466-8781 ❑ Lodi 369-3621 of ❑ Manteca 823-7104 ❑ Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA . EH 131410E .11e51 EH r&Z FEE INFO 1 AMOUNT DUE ::AMOUNT REMITTED Owner's Name(A yaej� Address - - - Phone DATE a Contractor 4q,4r11tk Address License No. L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O S 7- 2B 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 SPECIFICATI IS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -Minl dejAk Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Material itop 501 Depth Filler Material (Below 50) 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 Califomia." 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 must call for all required inspections. Complete drawing on reverse side. Signed x7�ltfZ Title: 5 J� Date: Application Accepted by Pit or Grout Date Z -2- 3 - V 7 -Area /40 Date Final Inspection by Additional Commdhfs: ❑ Stk 466-8781 ❑ Lodi 369-3621 of ❑ Manteca 823-7104 ❑ Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA . EH 131410E .11e51 EH r&Z FEE INFO 1 AMOUNT DUE ::AMOUNT REMITTED 1 H RECEIVED BY DATE PERMIT'NO. S . 09 �3 1 �a3ig S 7- 2B